Provider Demographics
NPI:1043423189
Name:SPACE COAST DERMATOLOGY CLINIC, PLLC
Entity Type:Organization
Organization Name:SPACE COAST DERMATOLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:EARHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-453-3360
Mailing Address - Street 1:695 CONE PARK CT
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3755
Mailing Address - Country:US
Mailing Address - Phone:321-453-3360
Mailing Address - Fax:321-453-4586
Practice Address - Street 1:695 CONE PARK CT
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3755
Practice Address - Country:US
Practice Address - Phone:321-453-3360
Practice Address - Fax:321-453-4586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00844Medicare ID - Type UnspecifiedSPACE COAST DERMATOLOGY