Basic Information
| Provider Information | |||||||||
| NPI: | 1043888985 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNIFYDX LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | DERMAGNIFY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EXECUTIVE WAY STE 114 | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320822713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556243376 | ||||||||
| FaxNumber: | 8776243376 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 EXECUTIVE WAY STE 114 | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320822713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048423632 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2021 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAPPEL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8556243376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.