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General NPI Number Information
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NPI Number | 1962487546
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Entity Type | Organization
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Legal Business Name | SUNNYCOAST DERMATOLOGY, INC.
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Dates
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Enumeration Date | 12/07/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1850 43RD AVE SUITE 4 & 5 C
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City | VERO BEACH
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State | FL
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Zip | 32960-0504
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Country | US
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Telephone | 772-299-4000
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Fax | 772-299-4001
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Provider Business Mailing Address
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Address Line | 1850 43RD AVE SUITE 4 & 5 C
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City | VERO BEACH
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State | FL
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Zip | 32960-0504
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Country | US
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Telephone | 772-299-4000
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Fax | 772-299-4001
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/MEDICAL DOCTOR
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Name | THEODOR MAJOR RUDOLPH
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Credential | M.D.
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Telephone | 772-299-4000
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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 | ME79805
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License Number State | FL
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