Healthcare Provider Details

I. General information

NPI: 1902890239
Provider Name (Legal Business Name): SUNCOAST DERMATOLOGY AND SKIN SURGERY CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N DACIE PT
LECANTO FL
34461-8399
US

IV. Provider business mailing address

525 N DACIE PT
LECANTO FL
34461-8399
US

V. Phone/Fax

Practice location:
  • Phone: 352-746-2200
  • Fax: 352-746-9320
Mailing address:
  • Phone: 352-746-2200
  • Fax: 352-746-9320

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
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RALPH EUGENE MASSULLO JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 352-746-2200