Basic Information
| Provider Information | |||||||||
| NPI: | 1902281025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKADEN | ||||||||
| FirstName: | JIBRIL | ||||||||
| MiddleName: | DIXON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S HARBOUR ISLAND BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273223439 | ||||||||
| FaxNumber: | 8009287449 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 E PLANT ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072876363 | ||||||||
| FaxNumber: | 8443886186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME133396 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 023627300 | 05 | FL | MEDICAID |