Healthcare Provider Details

I. General information

NPI: 1639856297
Provider Name (Legal Business Name): WATERSIDE DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 RIVERSIDE DR E STE 2200
BRADENTON FL
34208-1023
US

IV. Provider business mailing address

300 RIVERSIDE DR E STE 2200
BRADENTON FL
34208-1023
US

V. Phone/Fax

Practice location:
  • Phone: 941-748-3376
  • Fax: 941-748-7562
Mailing address:
  • Phone: 941-748-3376
  • Fax: 941-748-7562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ERFON EKHLASSI
Title or Position: OWNER AND PHYSICIAN
Credential: MD
Phone: 941-748-3376