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BOLD CITY DERMATOLOGY LLC
NPI 1538761655
Dermatology - MOHS-Micrographic Surgery in St Augustine, FL

Active since November 13, 2020CLIA Certified · 2 labs
316 PASEO REYES DR, ST AUGUSTINE, FL 32095(904) 544-5800(904) 544-5800 Get Directions Write a Review

NPPES record last updated: January 26, 2021. Verified against the NPPES registry weekly; last sync: August 16, 2026.

Record update history: Jan 26, 2021, Nov 20, 2020, Nov 13, 2020 (3 updates tracked since 2020).

About Bold City Dermatology Llc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

BOLD CITY DERMATOLOGY LLC (NPI 1538761655) is a healthcare organization registered as a mohs-micrographic surgery in St Augustine, Florida and active in the NPI registry since November 2020. The organization holds 2 active CLIA laboratory certificates and lists Bishr Al Dabagh, Owner, as its authorized official.

NPPES Registry Identity

NPI1538761655
Entity TypeOrganization
Primary Taxonomy207ND0101X
Legal Business NameBOLD CITY DERMATOLOGY LLC
Location Address316 PASEO REYES DRSt Augustine, FL 32095-8464
Mailing Address316 Paseo Reyes DrSt Augustine, FL 32095-8464 · (904) 544-5800
Phone(904) 544-5800
Fax(904) 544-5800
Organization SubpartNo
Authorized OfficialBishr Al DabaghOwner · (704) 230-1302
Enumeration DateNovember 13, 2020
Last NPPES UpdateJanuary 26, 20213 updates tracked since enumeration
NPPES CertifiedJanuary 26, 2021
✔ NPI 1538761655 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 4

★ Primary SpecialtyDermatology · MOHS-Micrographic SurgeryAllopathic & Osteopathic Physicians
Taxonomy Code207ND0101X
Definition
The highly-trained surgeons that perform Mohs Micrographic Surgery are specialists both in dermatology and pathology. With their extensive knowledge of the skin and unique pathological skills, they are able to remove only diseased tissue, preserving healthy tissue and minimizing the cosmetic impact of the surgery. Mohs surgeons who belong to the American College of Mohs Surgery (ACMS) have completed a minimum of one year of fellowship training at one of the ACMS-approved training centers in the U.S.
Also ListedDermatologyTaxonomy 207N00000X
Also ListedDermatology · Pediatric DermatologyTaxonomy 207NP0225X
Also ListedDermatology · Procedural DermatologyTaxonomy 207NS0135X
316 PASEO REYES DR, St Augustine, FL 32095
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Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X MULTIPLE SINGLE SPECIALTY GROUP

Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include Ambetter Health, Ambetter of Alabama, Florida Blue (BlueCross BlueShield FL) and more.Insurance ›

CLIA Laboratory Certificates CMS CLIA 2

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 10D2212163

Bold City Dermatology LLC · Saint Augustine, FL
Active · expires Jun 30, 2028
CLIA Number10D2212163
Laboratory TypePhysician Office
Certificate Effective DateJuly 1, 2026
Certificate Expiration DateJune 30, 2028
Laboratory DirectorBishr Ahmad Al-Dabagh
Laboratory Phone(904) 544-5800
Laboratory LocationBold City Dermatology LLC316 Paseo Reyes Dr, Saint Augustine, FL 32095
CLIA data matches this NPI record on: Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Certificate of Compliance 10D2280507

Bold City Dermatology LLC · Jacksonville, FL
Active · expires Oct 28, 2026
CLIA Number10D2280507
Laboratory TypePhysician Office
Certificate Effective DateOctober 29, 2024
Certificate Expiration DateOctober 28, 2026
Laboratory DirectorBishr A. Al-Dabagh
Laboratory Phone(904) 544-5800
Laboratory LocationBold City Dermatology LLC120 Gateway Circle Unit 1, Jacksonville, FL 32259
CLIA data matches this NPI record on: Name Phone
This certificate is issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements.

Other Providers at the Same Location NPPES 6

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

MS. ERGI SPAHO PA-C
Physician Assistant
316 PASEO REYES DR
ST AUGUSTINE, FL 32095
St. Johns County (904) 554-5800
MRS. KELLY AUCLAIR APRN
Nurse Practitioner (Family)
316 PASEO REYES DR
ST AUGUSTINE, FL 32095
St. Johns County (903) 544-5800
DR. MARY ELIZABETH RAY D.O.
Family Medicine
316 PASEO REYES DR
ST AUGUSTINE, FL 32095
St. Johns County (904) 342-0219
NICOLE RUSSO CAVIGNARO PA-C
Physician Assistant
316 PASEO REYES DR
ST AUGUSTINE, FL 32095
St. Johns County (904) 544-5800
OASIS MEDICAL PROVIDERS, LLC
Clinic/Center (Primary Care)
316 PASEO REYES DR
SAINT AUGUSTINE, FL 32095
St. Johns County (904) 342-0219
SARAH JEAN FERRER-BRUKER D.O.
Dermatology
316 PASEO REYES DR
ST AUGUSTINE, FL 32095
St. Johns County (904) 544-5800

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Bold City Dermatology LLC's NPI number?

The NPI number for Bold City Dermatology LLC is 1538761655. It was assigned to this organization in the NPPES registry on November 13, 2020.

Where is Bold City Dermatology LLC located?

Bold City Dermatology LLC is located at 316 Paseo Reyes Dr, St Augustine, FL 32095. The listed phone number is (904) 544-5800.

What is Bold City Dermatology LLC's specialty?

The primary specialty registered for this NPI is Dermatology, specializing in MOHS-Micrographic Surgery, with taxonomy code 207ND0101X.

Does Bold City Dermatology LLC hold CLIA laboratory certificates?

Yes. 2 active CLIA laboratory certificates are associated with this NPI under the federal Clinical Laboratory Improvement Amendments program. The certificates are listed in the CLIA Laboratory Certificates section above.

What insurance does Bold City Dermatology LLC accept?

Health plans from Ambetter Health, Ambetter of Alabama, Florida Blue (BlueCross BlueShield FL) and Florida Blue HMO (a BlueCross BlueShield FL company) list Bold City Dermatology LLC as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.

When was this NPI record last updated?

The NPPES record for Bold City Dermatology LLC was last updated on January 26, 2021. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 5 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.