1265856256 NPI number — SANDY MARTIN DERMATOLOGY LLC

Table of content: (NPI 1265856256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265856256 NPI number — SANDY MARTIN DERMATOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDY MARTIN DERMATOLOGY LLC
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:
6
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:
1265856256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1090 CAMELOT CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34119-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-706-5422
Provider Business Mailing Address Fax Number:
888-990-1670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13641 METROPOLIS AVE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-4433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-208-4408
Provider Business Practice Location Address Fax Number:
888-990-1670
Provider Enumeration Date:
02/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE MANAGER
Authorized Official Telephone Number:
239-208-4408

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  ME30746 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HS963A . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 93792T . This is a "MEDICARE PTAN FOR SANDY MARTIN MD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com