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General NPI Number Information
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NPI Number | 1386639912
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Entity Type | Organization
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Legal Business Name | EMERALD COAST DERMATOLOGY & SKIN SURGERY CENTER P A
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Dates
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Enumeration Date | 09/20/2005
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Last Update Date | 03/14/2025
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Provider Practice Location Address
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Address Line | 350 REDSTONE AVE W
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City | CRESTVIEW
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State | FL
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Zip | 32536-6433
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Country | US
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Telephone | 850-689-1740
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Fax | 850-682-6652
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Provider Business Mailing Address
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Address Line | 350 REDSTONE AVE W
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City | CRESTVIEW
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State | FL
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Zip | 32536-6433
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Country | US
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Telephone | 850-689-1740
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Fax | 850-682-6652
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Authorized Official
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Title or Position | CREDENTIALING AND CONTRACTING
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Name | JILLIAN OWENS
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Credential |
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Telephone | 850-689-1740
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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 | ME0061435
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License Number State | FL
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