Healthcare Provider Details

I. General information

NPI: 1710054556
Provider Name (Legal Business Name): DEEP SOUTH DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8573 COUNTY ROAD 64
DAPHNE AL
36526-8706
US

IV. Provider business mailing address

PO BOX 40
DAPHNE AL
36526-0040
US

V. Phone/Fax

Practice location:
  • Phone: 251-621-2244
  • Fax: 251-621-7209
Mailing address:
  • Phone: 251-621-2244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number00018113
License Number StateAL

VIII. Authorized Official

Name: DR. ALAN R STANFORD
Title or Position: OWNER
Credential: MD
Phone: 251-621-2244