Healthcare Provider Details

I. General information

NPI: 1265130413
Provider Name (Legal Business Name): PATRIOT DERMATOLOGY, SCORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5317 COLEWOOD PL
SARASOTA FL
34232-5607
US

IV. Provider business mailing address

638 LAWRENCEVILLE RD
LAWRENCE TOWNSHIP NJ
08648-4208
US

V. Phone/Fax

Practice location:
  • Phone: 941-500-4816
  • Fax:
Mailing address:
  • Phone: 609-337-7643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ERINE A KUPETSKY
Title or Position: OWNER, DERMATOLOGIST
Credential: DO
Phone: 609-337-7643