Healthcare Provider Details

I. General information

NPI: 1043222714
Provider Name (Legal Business Name): SCOTT C WICKLESS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S OSPREY AVE UNIT 201
SARASOTA FL
34239-3625
US

IV. Provider business mailing address

4919 MEMORIAL HWY STE 150
TAMPA FL
33634-7516
US

V. Phone/Fax

Practice location:
  • Phone: 941-957-4767
  • Fax: 941-955-7334
Mailing address:
  • Phone: 813-333-1528
  • Fax: 813-255-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberOS15286
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS15286
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: