Provider Demographics
NPI:1205240868
Name:SANFORD DERMATOLOGY PLLC
Entity type:Organization
Organization Name:SANFORD DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-314-2000
Mailing Address - Street 1:4700 EXCHANGE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4450
Mailing Address - Country:US
Mailing Address - Phone:561-314-2000
Mailing Address - Fax:
Practice Address - Street 1:1911 K M WICKER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5070
Practice Address - Country:US
Practice Address - Phone:919-775-7926
Practice Address - Fax:919-718-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty