Healthcare Provider Details

I. General information

NPI: 1871864264
Provider Name (Legal Business Name): SANDERS DERMATOLOGY AND SKIN CANCER CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 35TH LN SUITE 202
VERO BEACH FL
32960-6521
US

IV. Provider business mailing address

1155 35TH LN SUITE 202
VERO BEACH FL
32960-6521
US

V. Phone/Fax

Practice location:
  • Phone: 772-778-7782
  • Fax: 772-778-7879
Mailing address:
  • Phone: 772-778-7782
  • Fax: 772-778-7879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number87851
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number87851
License Number StateFL

VIII. Authorized Official

Name: JONATHAN SCOTT SANDERS
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 772-778-7782