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General NPI Number Information
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NPI Number | 1265856256
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Entity Type | Organization
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Legal Business Name | SANDY MARTIN DERMATOLOGY LLC
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Dates
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Enumeration Date | 02/11/2014
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Last Update Date | 08/04/2014
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Provider Practice Location Address
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Address Line | 13641 METROPOLIS AVE STE 102
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City | FORT MYERS
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State | FL
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Zip | 33912-4433
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Country | US
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Telephone | 239-208-4408
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Fax | 888-990-1670
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Provider Business Mailing Address
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Address Line | 1090 CAMELOT CIR
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City | NAPLES
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State | FL
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Zip | 34119-1308
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Country | US
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Telephone | 561-706-5422
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Fax | 888-990-1670
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Authorized Official
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Title or Position | CHIEF EXECUTIVE MANAGER
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Name | DR. SANDY MARTIN
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Credential | MD
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Telephone | 239-208-4408
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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 | ME30746
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License Number State | FL
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