Healthcare Provider Details

I. General information

NPI: 1558824912
Provider Name (Legal Business Name): AVERY CAMILLE CHISHOLM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462626 STATE ROAD 200 STE 300
YULEE FL
32097-5516
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-7205
  • Fax:
Mailing address:
  • Phone: 904-504-8195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME175195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: