Organization
BOLD CITY DERMATOLOGY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BISHR AL DABAGH MD (OWNER)
(704) 230-1302
Entity
Organization
Contact information
Practice address
316 PASEO REYES DR, ST AUGUSTINE, FL 32095-8464
(904) 544-5800
(904) 544-5800
Mailing address
316 PASEO REYES DR, ST AUGUSTINE, FL 32095-8464
(904) 544-5800
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
—
—
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
—
—
207NP0225X
Pediatric Dermatology Physician
—
—
207NS0135X
Procedural Dermatology Physician
—
—
Other
Enumeration date
11/13/2020
Last updated
01/26/2021
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