1275538274 NPI number — ASSOCIATES IN MEDICAL AND SURGICAL DERMATOLOGY, P.A.

Table of content: SHURON DE LA CRUZ (NPI 1699651331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275538274 NPI number — ASSOCIATES IN MEDICAL AND SURGICAL DERMATOLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSOCIATES IN MEDICAL AND SURGICAL DERMATOLOGY, P.A.
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275538274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9125 CORSEA DEL FONTANA WAY
Provider Second Line Business Mailing Address:
# 100
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34109-4396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-598-4004
Provider Business Mailing Address Fax Number:
239-598-4713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9125 CORSEA DEL FONTANA WAY
Provider Second Line Business Practice Location Address:
# 100
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34109-4396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-598-4004
Provider Business Practice Location Address Fax Number:
239-598-4713
Provider Enumeration Date:
06/16/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
SETH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
239-598-4004

Provider Taxonomy Codes

  • Taxonomy code: 173000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42568 . This is a "TUCKER BLUE CROSS #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 04756 . This is a "GOODMAN BLUE CROSS #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 45192 . This is a "GROUP BLUE CROSS #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".