Healthcare Provider Details

I. General information

NPI: 1538761655
Provider Name (Legal Business Name): BOLD CITY DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 PASEO REYES DR
ST AUGUSTINE FL
32095-8464
US

IV. Provider business mailing address

316 PASEO REYES DR
ST AUGUSTINE FL
32095-8464
US

V. Phone/Fax

Practice location:
  • Phone: 904-544-5800
  • Fax: 904-544-5800
Mailing address:
  • Phone: 904-544-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BISHR AL DABAGH
Title or Position: OWNER
Credential: MD
Phone: 704-230-1302