1205240868 NPI number — INTEGRATED DERMATOLOGY OF SANFORD, PLLC

Table of content: (NPI 1205240868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205240868 NPI number — INTEGRATED DERMATOLOGY OF SANFORD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
INTEGRATED DERMATOLOGY OF SANFORD, PLLC
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:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1205240868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 EXCHANGE CT STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-4450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-314-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 S HORNER BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27330-5342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-775-7926
Provider Business Practice Location Address Fax Number:
919-718-0092
Provider Enumeration Date:
06/11/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
QUEEN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
561-314-2000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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