Provider Demographics
NPI:1518089846
Name:FIRST COAST DERMATOLOGY AND INTERNAL MEDICINE P A
Entity Type:Organization
Organization Name:FIRST COAST DERMATOLOGY AND INTERNAL MEDICINE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:O
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-249-6110
Mailing Address - Street 1:3200 3RD ST S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6056
Mailing Address - Country:US
Mailing Address - Phone:904-249-6110
Mailing Address - Fax:904-249-6119
Practice Address - Street 1:3200 3RD ST S
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6056
Practice Address - Country:US
Practice Address - Phone:904-249-6110
Practice Address - Fax:904-249-6119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
FLME81110207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4585Medicare ID - Type Unspecified