=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750623328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERACE LAN SCHAFFER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2013
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2263 CLINTON AVE S
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-263-2945
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 GRAND ISLE DR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34108-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-612-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 131830-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------