=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043221997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY PARK DERMATOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 12/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8451 SHADE AVE SUITE 205
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34243-2878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-360-2477
-----------------------------------------------------
Fax | 941-360-2577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8451 SHADE AVE SUITE 205
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34243-2878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-360-2477
-----------------------------------------------------
Fax | 941-360-2577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID SAX
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-360-2477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | ME83476
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------