Healthcare Provider Details

I. General information

NPI: 1518256932
Provider Name (Legal Business Name): SEAN MAZLOOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 COMMERCIAL CT STE C
VENICE FL
34292-1651
US

IV. Provider business mailing address

2389 E VENICE AVE UNIT 510
VENICE FL
34292-2465
US

V. Phone/Fax

Practice location:
  • Phone: 941-529-0070
  • Fax: 941-529-0539
Mailing address:
  • Phone: 941-946-7570
  • Fax: 941-240-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME145595
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME145595
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME145595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: