Basic Information
| Provider Information | |||||||||
| NPI: | 1295886539 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ISLAND COAST DERMATOLOGY, PA | ||||||||
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| OtherOrganizationName: | ISLAND COAST DERMATOLOGY, PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7310 COLLEGE PKWY | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339075503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397686100 | ||||||||
| FaxNumber: | 2395613763 | ||||||||
| Practice Location | |||||||||
| Address1: | 7310 COLLEGE PKWY | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339075503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397686100 | ||||||||
| FaxNumber: | 2395613763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 2397686100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | OS0006359 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | P00295648 | 01 | FL | PA'S RAILROAD MEDICARE # | OTHER | 44584 | 01 | FL | BCBS | OTHER | DE4849 | 01 | FL | RAILROAD GROUP # | OTHER | 070012707 | 01 | FL | RAILROAD MEDICARE | OTHER |