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NPI Code Detail

MEDICARE: SUN DERMATOLOGY LLC

MEDICARE: SUN DERMATOLOGY LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207ND0101XMOHS-Micrographic Surgery Physician
2207N00000XDermatology Physician

General Provider Information

NPI Number : 1407207111
Entity Type Code : Organization
Provider Name (Legal Business Name) : SUN DERMATOLOGY LLC
Provider Business Mailing Address
First Line : 2101 JENKS AVE
Second Line :
City : PANAMA CITY
State : FL
Zip : 32405-4511
Country : US
Telephone Number : 334-791-5423
Fax Number :
Provider Business Practice Location Address
First Line : 2101 JENKS AVE
Second Line :
City : PANAMA CITY
State : FL
Zip : 32405-4511
Country : US
Telephone Number : 334-791-5423
Fax Number :
Authorized Official
Title or Position : AUTHORIZED MEMBER
Name : LEONARD TERRY PYNES
Credential : MD
Telephone Number : 334-791-5423
Provider Enumeration Date : 06/23/2016
Last Update Date : 06/23/2016

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