Healthcare Provider Details

I. General information

NPI: 1215142567
Provider Name (Legal Business Name): FORT MYERS DERMATOPATHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 CAPE CORAL PKWY E SUITE E
CAPE CORAL FL
33904-8549
US

IV. Provider business mailing address

8381 RIVERWALK PARK BLVD SUITE 202
FORT MYERS FL
33919-8760
US

V. Phone/Fax

Practice location:
  • Phone: 239-549-0837
  • Fax: 239-549-8766
Mailing address:
  • Phone: 239-274-0005
  • Fax: 239-278-4718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MAZEN DAOUD
Title or Position: PRESIDENT
Credential: MD
Phone: 239-274-0005