Provider Demographics
NPI:1609078542
Name:POWELL, FRED JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:JOE
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:111 NATURE WALK PARKWAY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092
Mailing Address - Country:US
Mailing Address - Phone:904-230-7180
Mailing Address - Fax:904-230-7181
Practice Address - Street 1:111 NATURE WALK PARKWAY
Practice Address - Street 2:SUITE 108
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:904-230-7180
Practice Address - Fax:904-230-7181
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 809962086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery