Healthcare Provider Details

I. General information

NPI: 1649676669
Provider Name (Legal Business Name): BREVARD MEDICAL DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7960 N. WICKHAM ROAD SUITE 103
MELBOURNE FL
32940-8096
US

IV. Provider business mailing address

7960 N. WICKHAM ROAD SUITE 103
MELBOURNE FL
32940-8096
US

V. Phone/Fax

Practice location:
  • Phone: 321-428-4737
  • Fax: 321-241-6457
Mailing address:
  • Phone: 321-428-4737
  • Fax: 321-241-6457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL SPICER
Title or Position: PRESIDENT
Credential: MD
Phone: 321-428-4737