Provider Demographics
NPI:1366657629
Name:FORT MYERS DERMATOPATHOLOGY
Entity Type:Organization
Organization Name:FORT MYERS DERMATOPATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-274-0005
Mailing Address - Street 1:8381 RIVERWALK PARK BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8760
Mailing Address - Country:US
Mailing Address - Phone:239-274-0005
Mailing Address - Fax:239-278-4718
Practice Address - Street 1:9250 CORKSCREW RD
Practice Address - Street 2:SUITE 5
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-3208
Practice Address - Country:US
Practice Address - Phone:239-274-0005
Practice Address - Fax:239-278-4718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty