Healthcare Provider Details

I. General information

NPI: 1801369020
Provider Name (Legal Business Name): VENICE DERMATOLOGY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3171 BOBCAT VILLAGE CENTER RD
NORTH PORT FL
34288-8974
US

IV. Provider business mailing address

1219 JACARANDA BLVD
VENICE FL
34292-4520
US

V. Phone/Fax

Practice location:
  • Phone: 941-484-2250
  • Fax:
Mailing address:
  • Phone: 941-484-2250
  • Fax: 941-484-9638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRUCE ALLEN BOYD
Title or Position: M.D./OWNER
Credential:
Phone: 941-484-2250