Provider Demographics
NPI:1700059623
Name:ROBERT B DEHGAN M D P A
Entity Type:Organization
Organization Name:ROBERT B DEHGAN M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:DEHGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-247-1919
Mailing Address - Street 1:460 OSCEOLA AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4078
Mailing Address - Country:US
Mailing Address - Phone:904-247-1919
Mailing Address - Fax:904-246-0301
Practice Address - Street 1:1 ORTHOPAEDIC PL
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4202
Practice Address - Country:US
Practice Address - Phone:904-247-1919
Practice Address - Fax:904-246-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME16903208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049429100Medicaid
FL250011286OtherRR MEDICARE
FL16803OtherBCBS
FLD85161Medicare UPIN
FL049429100Medicaid