Provider Demographics
NPI:1720177264
Name:O LEARY, JOAN DUNSTONE (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:DUNSTONE
Last Name:O LEARY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 KINGSLEY AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-9204
Mailing Address - Country:US
Mailing Address - Phone:904-278-3100
Mailing Address - Fax:904-278-4463
Practice Address - Street 1:1555 KINGSLEY AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-9204
Practice Address - Country:US
Practice Address - Phone:904-278-3100
Practice Address - Fax:904-278-4463
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064412207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18934OtherBLUE CROSS BLUE SHIELD
FL18934OtherBLUE CROSS BLUE SHIELD
F61420Medicare UPIN