Provider Demographics
NPI:1073883617
Name:BONITA DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:BONITA DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZY
Authorized Official - Middle Name:POPE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-593-1632
Mailing Address - Street 1:9411 FOUNTAIN MEDICAL CT STE 100
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4625
Mailing Address - Country:US
Mailing Address - Phone:239-593-1632
Mailing Address - Fax:
Practice Address - Street 1:9411 FOUNTAIN MEDICAL CT STE 100
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4625
Practice Address - Country:US
Practice Address - Phone:239-593-1632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty