1265856256 NPI number — SANDY MARTIN DERMATOLOGY LLC

Table of Contents

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".




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