Provider Demographics
NPI:1386639912
Name:EMERALD COAST DERMATOLOGY & SKIN SURGERY CENTER P A
Entity Type:Organization
Organization Name:EMERALD COAST DERMATOLOGY & SKIN SURGERY CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:TRAPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-689-1740
Mailing Address - Street 1:350 REDSTONE AVE W
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6433
Mailing Address - Country:US
Mailing Address - Phone:850-689-1740
Mailing Address - Fax:850-682-6652
Practice Address - Street 1:350 REDSTONE AVE W
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6433
Practice Address - Country:US
Practice Address - Phone:850-689-1740
Practice Address - Fax:850-689-1740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061435207N00000X
FLME89393207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K3604Medicare ID - Type Unspecified