Healthcare Provider Details

I. General information

NPI: 1821285438
Provider Name (Legal Business Name): TULANE DERMATOLOGY AFFILIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 42ND AVENUE
GULFPORT MS
39501
US

IV. Provider business mailing address

1245 42ND AVENUE
GULFPORT MS
39501
US

V. Phone/Fax

Practice location:
  • Phone: 228-864-8049
  • Fax: 228-864-7655
Mailing address:
  • Phone: 228-864-8049
  • Fax: 228-864-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PATRICIA E. DEPREO
Title or Position: OFFICE MANAGER
Credential:
Phone: 228-864-8049