=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891805057
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTIN PAUL YUNGMANN DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2893 ENTERPRISE RD STE 100
-----------------------------------------------------
City | DEBARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32713-2784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-789-8600
-----------------------------------------------------
Fax | 386-789-0219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 SOUTHHALL LN STE 300
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-875-2080
-----------------------------------------------------
Fax | 407-650-3455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | OS6376
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------