Provider Demographics
NPI:1336315639
Name:PARKWAY PLASTIC SURGERY, P.L.
Entity Type:Organization
Organization Name:PARKWAY PLASTIC SURGERY, P.L.
Other - Org Name:PARKWAY PLASTIC SURGERY PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-396-1186
Mailing Address - Street 1:5101 GATE PKWY, SUITE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7275
Mailing Address - Country:US
Mailing Address - Phone:904-396-1186
Mailing Address - Fax:904-396-0228
Practice Address - Street 1:5101 GATE PKWY, SUITE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7275
Practice Address - Country:US
Practice Address - Phone:904-396-1186
Practice Address - Fax:904-396-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0020849174400000X
FLME77532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58269Medicare UPIN
FLH17497Medicare UPIN
H17497Medicare UPIN
FL71985Medicare PIN