Provider Demographics
NPI:1639513757
Name:DEEGAN, BRIAN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JOHN
Last Name:DEEGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 A C SKINNER PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:2370 MARKET DR
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003
Practice Address - Country:US
Practice Address - Phone:904-264-6201
Practice Address - Fax:904-264-6858
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1350852085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH6U17OtherFL BLUE
FLJK033ZOtherMEDICARE
FLP02093071OtherRR MEDICARE
FL024277400Medicaid