Healthcare Provider Details

I. General information

NPI: 1386639912
Provider Name (Legal Business Name): EMERALD COAST DERMATOLOGY & SKIN SURGERY CENTER P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 REDSTONE AVE W
CRESTVIEW FL
32536-6433
US

IV. Provider business mailing address

350 REDSTONE AVE W
CRESTVIEW FL
32536-6433
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-1740
  • Fax: 850-682-6652
Mailing address:
  • Phone: 850-689-1740
  • Fax: 850-682-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME0061435
License Number StateFL

VIII. Authorized Official

Name: JILLIAN OWENS
Title or Position: CREDENTIALING AND CONTRACTING
Credential:
Phone: 850-689-1740