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General NPI Number Information
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NPI Number | 1295886539
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Entity Type | Organization
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Legal Business Name | ISLAND COAST DERMATOLOGY, PA
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Dates
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Enumeration Date | 01/15/2007
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Last Update Date | 06/24/2008
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Provider Practice Location Address
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Address Line | 7310 COLLEGE PKWY
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City | FORT MYERS
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State | FL
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Zip | 33907-5503
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Country | US
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Telephone | 239-768-6100
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Fax | 239-561-3763
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Provider Business Mailing Address
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Address Line | 7310 COLLEGE PKWY
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City | FORT MYERS
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State | FL
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Zip | 33907-5503
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Country | US
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Telephone | 239-768-6100
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Fax | 239-561-3763
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | DR. JEFFREY N MARTIN
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Credential | D.O.
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Telephone | 239-768-6100
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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 | OS0006359
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License Number State | FL
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