Provider Demographics
NPI:1740703818
Name:CREEKSIDE DERMATOLOGY PA
Entity type:Organization
Organization Name:CREEKSIDE DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CASPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-399-7295
Mailing Address - Street 1:8620 E COUNTY ROAD 466
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-3670
Mailing Address - Country:US
Mailing Address - Phone:352-399-7295
Mailing Address - Fax:
Practice Address - Street 1:8630 E COUNTY ROAD 466 STE A
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5614
Practice Address - Country:US
Practice Address - Phone:352-399-7295
Practice Address - Fax:352-399-7294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL108772207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty