Individual
SUMMER MOON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
115 HIGHLAND AVE N, LARGO, FL 33770
(727) 585-8591
(727) 584-0614
Mailing address
115 HIGHLAND AVE N, LARGO, FL 33770-2530
(727) 858-8591
(727) 584-0614
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
5101021452
MI
207N00000X
Dermatology Physician
Primary
OS14644
FL
207NS0135X
Procedural Dermatology Physician
OS14644
FL
Other
Enumeration date
06/12/2014
Last updated
11/20/2018
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