Healthcare Provider Details

I. General information

NPI: 1730391061
Provider Name (Legal Business Name): SUSAN H WEINKLE, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 21ST AVE W STE B
BRADENTON FL
34209-5642
US

IV. Provider business mailing address

5601 21ST AVE W STE B
BRADENTON FL
34209-5642
US

V. Phone/Fax

Practice location:
  • Phone: 941-794-5432
  • Fax: 941-794-5682
Mailing address:
  • Phone: 941-794-5432
  • Fax: 941-794-5682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number45450
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number45450
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number45450
License Number StateFL

VIII. Authorized Official

Name: DR. SUSAN HOLLOWAY WEINKLE
Title or Position: OWNER
Credential: M.D.
Phone: 941-794-5432