Provider Demographics
NPI:1194079988
Name:INTRACOASTAL DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:INTRACOASTAL DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:ADKISSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-655-5310
Mailing Address - Street 1:4776 HODGES BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-7218
Mailing Address - Country:US
Mailing Address - Phone:904-655-5310
Mailing Address - Fax:
Practice Address - Street 1:4776 HODGES BLVD STE 105
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7218
Practice Address - Country:US
Practice Address - Phone:904-655-5310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110325207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty