Provider Demographics
NPI:1215101902
Name:21ST CENTURY ONCOLOGY OF JACKSONVILLE LLC
Entity type:Organization
Organization Name:21ST CENTURY ONCOLOGY OF JACKSONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOSORETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-931-7275
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1235 SAN MARCO BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8554
Practice Address - Country:US
Practice Address - Phone:904-493-5100
Practice Address - Fax:904-493-5130
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIATION THERAPY SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-15
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL281173104Medicaid
FL281173100Medicaid
FL281173101Medicaid
FL281173102Medicaid
FL281173103Medicaid
FL281173102Medicaid