Provider Demographics
NPI:1801369020
Name:VENICE DERMATOLOGY CLINIC PA
Entity Type:Organization
Organization Name:VENICE DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-484-2250
Mailing Address - Street 1:1219 JACARANDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-4520
Mailing Address - Country:US
Mailing Address - Phone:941-484-2250
Mailing Address - Fax:941-484-9638
Practice Address - Street 1:3171 BOBCAT VILLAGE CENTER RD
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-8974
Practice Address - Country:US
Practice Address - Phone:941-484-2250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VENICE DERMATOLOGY CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty