Healthcare Provider Details

I. General information

NPI: 1124646930
Provider Name (Legal Business Name): NEIL SANDHU PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 TREEMONTE DR STE 258
ORANGE CITY FL
32763-7945
US

IV. Provider business mailing address

258 TREEMONTE DR STE 258
ORANGE CITY FL
32763-7945
US

V. Phone/Fax

Practice location:
  • Phone: 386-628-3376
  • Fax:
Mailing address:
  • Phone: 386-628-3376
  • Fax: 386-877-0188

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: NEIL SANDHU
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 386-628-3376