Provider Demographics
NPI:1629322706
Name:OGBURN, DOUGLAS RAYFIELD (PA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RAYFIELD
Last Name:OGBURN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-396-6620
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:858 MONUMENT RD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-450-6600
Practice Address - Fax:904-450-6369
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106950363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant