Provider Demographics
NPI:1770693012
Name:GULF SHORE DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:GULF SHORE DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:TORP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-818-1850
Mailing Address - Street 1:1304 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2552
Mailing Address - Country:US
Mailing Address - Phone:228-868-4006
Mailing Address - Fax:228-822-2461
Practice Address - Street 1:2112 BIENVILLE BLVD
Practice Address - Street 2:SUITE F1
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3052
Practice Address - Country:US
Practice Address - Phone:228-818-1850
Practice Address - Fax:228-818-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14315207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09324843Medicaid
MSC03562Medicare PIN