Healthcare Provider Details

I. General information

NPI: 1255325049
Provider Name (Legal Business Name): LARRY S BISHOP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 MURRELL RD
MELBOURNE FL
32940-7999
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-242-8790
  • Fax: 321-751-9362
Mailing address:
  • Phone: 321-361-5606
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME67730
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: