Provider Demographics
NPI:1679574164
Name:N FRED EAGLSTEIN DO PA
Entity Type:Organization
Organization Name:N FRED EAGLSTEIN DO PA
Other - Org Name:DERMATOLOGY AND LASER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:N
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:EAGLSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-276-4500
Mailing Address - Street 1:2055 PROFESSIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4461
Mailing Address - Country:US
Mailing Address - Phone:904-276-4500
Mailing Address - Fax:904-276-4160
Practice Address - Street 1:2055 PROFESSIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4461
Practice Address - Country:US
Practice Address - Phone:904-276-4500
Practice Address - Fax:904-276-4160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043624100Medicaid
FL39768Medicare PIN