Provider Demographics
NPI:1093496432
Name:SUN STATE DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:SUN STATE DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHOO
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAJIV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-636-3113
Mailing Address - Street 1:430 LAKE HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5907
Mailing Address - Country:US
Mailing Address - Phone:407-636-3113
Mailing Address - Fax:407-636-3133
Practice Address - Street 1:430 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5907
Practice Address - Country:US
Practice Address - Phone:407-636-3113
Practice Address - Fax:407-636-3133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty