Provider Demographics
NPI:1588985972
Name:JACKSONVILLE PLASTIC SURGERY INC
Entity type:Organization
Organization Name:JACKSONVILLE PLASTIC SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:OBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-346-0060
Mailing Address - Street 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-346-0060
Mailing Address - Fax:904-346-0065
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 1600
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-346-0060
Practice Address - Fax:904-346-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-20
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME027754208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55094OtherMEDICARE ID NUMBER