Provider Demographics
NPI:1750555777
Name:ROBERT B DEHGAN MD PA
Entity type:Organization
Organization Name:ROBERT B DEHGAN MD PA
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:
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 1:460 OSCEOLA AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-4078
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:2008-04-22
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 16903204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16803OtherBCBS
FL250011286OtherRR MEDICARE
FL049429100Medicaid
FLD85161Medicare UPIN
FL049429100Medicaid