1275522054 NPI number — MYERS & FOTOPOULOS MDS PA

Table of content: (NPI 1275522054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275522054 NPI number — MYERS & FOTOPOULOS MDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYERS & FOTOPOULOS MDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEW IMAGE DERMATOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275522054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5534 GULF DR
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
NEW PORT RICHEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34652-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-847-3992
Provider Business Mailing Address Fax Number:
727-848-1118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5534 GULF DR
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
NEW PORT RICHEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34652-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-847-3992
Provider Business Practice Location Address Fax Number:
727-848-1118
Provider Enumeration Date:
10/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FOTOPOULOS
Authorized Official First Name:
THEODORE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
727-847-3992

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8550571-00 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 34711 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CC5751 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103291800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com