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General NPI Number Information
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NPI Number | 1073870341
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Entity Type | Organization
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Legal Business Name | FLORIDA CENTER FOR DERMATOLOGY, P.A.
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Dates
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Enumeration Date | 04/11/2012
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Last Update Date | 04/11/2012
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Provider Practice Location Address
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Address Line | 105 SOUTHPARK BLVD SUITE A103
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5191
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Country | US
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Telephone | 904-342-7765
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Fax | 904-342-7770
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Provider Business Mailing Address
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Address Line | 105 SOUTHPARK BLVD SUITE A103
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5191
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Country | US
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Telephone | 904-342-7765
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Fax | 904-342-7770
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JONATHAN KANTOR
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Credential | M.D.
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Telephone | 904-342-7765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | ME92201
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License Number State | FL
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