Provider Demographics
NPI:1265856256
Name:SANDY MARTIN DERMATOLOGY LLC
Entity Type:Organization
Organization Name:SANDY MARTIN DERMATOLOGY LLC
Other - Org Name:MARTIN DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-208-4408
Mailing Address - Street 1:1090 CAMELOT CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-1308
Mailing Address - Country:US
Mailing Address - Phone:561-706-5422
Mailing Address - Fax:888-990-1670
Practice Address - Street 1:13641 METROPOLIS AVE
Practice Address - Street 2:STE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4433
Practice Address - Country:US
Practice Address - Phone:239-208-4408
Practice Address - Fax:888-990-1670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-11
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30746207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHS963AOtherMEDICARE PTAN
FL93792TOtherMEDICARE PTAN FOR SANDY MARTIN MD
FLHS963AOtherMEDICARE PTAN