Provider Demographics
NPI:1073870341
Name:FLORIDA CENTER FOR DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:FLORIDA CENTER FOR DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-342-7765
Mailing Address - Street 1:105 SOUTHPARK BLVD
Mailing Address - Street 2:SUITE A103
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5191
Mailing Address - Country:US
Mailing Address - Phone:904-342-7765
Mailing Address - Fax:904-342-7770
Practice Address - Street 1:105 SOUTHPARK BLVD
Practice Address - Street 2:SUITE A103
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5191
Practice Address - Country:US
Practice Address - Phone:904-342-7765
Practice Address - Fax:904-342-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92201207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty