Provider Demographics
NPI:1487827416
Name:SUNCOAST SKIN SOLUTIONS
Entity Type:Organization
Organization Name:SUNCOAST SKIN SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:EWANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-321-1786
Mailing Address - Street 1:4651 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-321-1786
Mailing Address - Fax:813-321-1787
Practice Address - Street 1:4651 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4880
Practice Address - Country:US
Practice Address - Phone:813-321-1786
Practice Address - Fax:813-321-1787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100378207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001793700Medicaid