Provider Demographics
NPI:1558315234
Name:SAND LAKE DERMATOLOGY CENTER, P.A.
Entity Type:Organization
Organization Name:SAND LAKE DERMATOLOGY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ARTHUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-352-8553
Mailing Address - Street 1:7335 W SAND LAKE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5538
Mailing Address - Country:US
Mailing Address - Phone:407-352-8553
Mailing Address - Fax:407-351-8412
Practice Address - Street 1:7335 W SAND LAKE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5538
Practice Address - Country:US
Practice Address - Phone:407-352-8553
Practice Address - Fax:407-351-8412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050669174400000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04979ZMedicare ID - Type UnspecifiedMEDICARE GROUP #
FLD09050Medicare UPIN