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General NPI Number Information
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NPI Number | 1457765968
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Entity Type | Individual
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Provider Name | SUMMER MOON DO
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Gender | Female
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Dates
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Enumeration Date | 06/12/2014
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Last Update Date | 11/20/2018
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Provider Practice Location Address
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Address Line | 115 HIGHLAND AVE N
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City | LARGO
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State | FL
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Zip | 33770
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Country | US
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Telephone | 727-585-8591
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Fax | 727-584-0614
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Provider Business Mailing Address
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Address Line | 115 HIGHLAND AVE N
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City | LARGO
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State | FL
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Zip | 33770-2530
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Country | US
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Telephone | 727-858-8591
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Fax | 727-584-0614
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 5101021452
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | OS14644
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | OS14644
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License Number State | FL
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