Provider Demographics
NPI:1609975374
Name:JOHN MORELLO MD
Entity Type:Organization
Organization Name:JOHN MORELLO MD
Other - Org Name:ATLANTIC BOULEVARD DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-221-3100
Mailing Address - Street 1:2295 OCEANSIDE CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-5957
Mailing Address - Country:US
Mailing Address - Phone:904-247-6461
Mailing Address - Fax:904-247-2686
Practice Address - Street 1:13111 ATLANTIC BLVD
Practice Address - Street 2:SUITE #4
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-221-3100
Practice Address - Fax:904-221-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63627207N00000X, 207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28207OtherBCBS OF FL
FLBM3444231OtherDEA
FL28207OtherBCBS OF FL
FL28207Medicare ID - Type Unspecified