Provider Demographics
NPI:1063836773
Name:BOCA GRANDE DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:BOCA GRANDE DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:COREY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:941-855-9372
Mailing Address - Street 1:PO BOX 1883
Mailing Address - Street 2:415 ROCK DOVE DR
Mailing Address - City:BOCA GRANDE
Mailing Address - State:FL
Mailing Address - Zip Code:33921-1883
Mailing Address - Country:US
Mailing Address - Phone:941-855-9372
Mailing Address - Fax:
Practice Address - Street 1:320 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:BOCA GRANDE
Practice Address - State:FL
Practice Address - Zip Code:33921
Practice Address - Country:US
Practice Address - Phone:941-964-0490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-17
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116621207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HR930AMedicare UPIN