Provider Demographics
NPI:1003007840
Name:VENICE DERMATOLOGY CLINIC PA
Entity Type:Organization
Organization Name:VENICE DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-484-2250
Mailing Address - Street 1:716 THE RIALTO
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3524
Mailing Address - Country:US
Mailing Address - Phone:941-484-2250
Mailing Address - Fax:941-484-9638
Practice Address - Street 1:716 THE RIALTO
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3524
Practice Address - Country:US
Practice Address - Phone:941-484-2250
Practice Address - Fax:941-484-9638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69164207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIK3312Medicare PIN
FLF67550Medicare UPIN