Provider Demographics
NPI:1043221997
Name:UNIVERSITY PARK DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:UNIVERSITY PARK DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-360-2477
Mailing Address - Street 1:8451 SHADE AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2878
Mailing Address - Country:US
Mailing Address - Phone:941-360-2477
Mailing Address - Fax:941-360-2577
Practice Address - Street 1:8451 SHADE AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2878
Practice Address - Country:US
Practice Address - Phone:941-360-2477
Practice Address - Fax:941-360-2577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83476207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06331OtherGROUP BC NUMBER
FLK3151Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER