Provider Demographics
NPI:1013973320
Name:FORT MYERS DERMATOPATHOLOGY PA
Entity type:Organization
Organization Name:FORT MYERS DERMATOPATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-274-0005
Mailing Address - Street 1:8381 RIVERWALK PARK BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919
Mailing Address - Country:US
Mailing Address - Phone:239-274-0005
Mailing Address - Fax:239-274-8185
Practice Address - Street 1:8381 RIVERWALK PARK BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-274-0005
Practice Address - Fax:239-274-8185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
202599OtherWELLCARE STAYWELL
FL06492OtherBCBS
284777OtherAVMED
FL202599OtherWELLCARE
=========OtherUNITED HEALTHCARE
=========OtherWEB TPA
=========OtherBEECHSTREET
=========OtherCIGNA
FL202599OtherWELLCARE
FL06492OtherBCBS
284777OtherAVMED
284777OtherAVMED
=========OtherWEB TPA