Provider Demographics
NPI:1588215362
Name:PURPLE DOGFISH LLC
Entity Type:Organization
Organization Name:PURPLE DOGFISH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ODERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-954-3698
Mailing Address - Street 1:PO BOX 18186
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34276-1186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6150 EDGELAKE DR
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-8803
Practice Address - Country:US
Practice Address - Phone:541-954-3698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty