Provider Demographics
NPI:1962487546
Name:SUNNYCOAST DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:SUNNYCOAST DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:THEODOR
Authorized Official - Middle Name:MAJOR
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-299-4000
Mailing Address - Street 1:1850 43RD AVE
Mailing Address - Street 2:SUITE 4 & 5 C
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-0504
Mailing Address - Country:US
Mailing Address - Phone:772-299-4000
Mailing Address - Fax:772-299-4001
Practice Address - Street 1:1850 43RD AVE
Practice Address - Street 2:SUITE 4 & 5 C
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0504
Practice Address - Country:US
Practice Address - Phone:772-299-4000
Practice Address - Fax:772-299-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79805207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2776Medicare ID - Type Unspecified