Healthcare Provider Details

I. General information

NPI: 1740703818
Provider Name (Legal Business Name): CREEKSIDE DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8630 E COUNTY ROAD 466 STE A
THE VILLAGES FL
32162-5614
US

IV. Provider business mailing address

8620 E COUNTY ROAD 466
THE VILLAGES FL
32162-3670
US

V. Phone/Fax

Practice location:
  • Phone: 352-399-7295
  • Fax: 352-399-7294
Mailing address:
  • Phone: 352-399-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number108772
License Number StateFL

VIII. Authorized Official

Name: DR. DAVID CASPER
Title or Position: PRESIDENT
Credential: MD
Phone: 352-399-7295