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General NPI Number Information
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NPI Number | 1205353687
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Entity Type | Organization
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Legal Business Name | GULFSHORE DERMATOLOGY, P.A.
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Dates
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Enumeration Date | 08/25/2017
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Last Update Date | 08/25/2017
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Provider Practice Location Address
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Address Line | 15620 NEW HAMPSHIRE CT
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City | FORT MYERS
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State | FL
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Zip | 33908-4168
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Country | US
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Telephone | 239-415-0004
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 835
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City | TRUSSVILLE
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State | AL
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Zip | 35173-0835
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Country | US
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Telephone | 205-746-7752
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Fax | 205-836-3482
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Authorized Official
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Title or Position | PRESIDENT / PHYSICIAN
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Name | JEFFREY NEAL MARTIN
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Credential | D.O.
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Telephone | 239-415-0004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | OS6359
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License Number State | FL
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