Healthcare Provider Details

I. General information

NPI: 1073409868
Provider Name (Legal Business Name): CYPRESS CROWN DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 RIDGE CENTER DR STE 203
DAVENPORT FL
33837-6416
US

IV. Provider business mailing address

229 W LAKE SUMMIT DR
WINTER HAVEN FL
33884-1528
US

V. Phone/Fax

Practice location:
  • Phone: 863-667-6647
  • Fax: 312-276-8889
Mailing address:
  • Phone: 216-246-0269
  • Fax: 312-276-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: REBECCA TUNG
Title or Position: OWNER
Credential: MD
Phone: 216-246-0269