Provider Demographics
NPI:1205080652
Name:ADKISSON, CAMERON DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:DAVID
Last Name:ADKISSON
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 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:#300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1613
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:14540 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:2571
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7418
Practice Address - Country:US
Practice Address - Phone:904-886-2251
Practice Address - Fax:904-886-7151
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIMD447547208600000X
MN57500208600000X
FLME105034208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI506JOtherBCBS-FL
FLIE505ZMedicare PIN