Organization
SUNCOAST DERMATOLOGY AND SKIN SURGERY CENTER, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RALPH EUGENE MASSULLO JR. MD (PRESIDENT)
(352) 746-2200
Entity
Organization
Contact information
Practice address
525 N DACIE PT, LECANTO, FL 34461-8399
(352) 746-2200
(352) 746-9320
Mailing address
525 N DACIE PT, LECANTO, FL 34461-8399
(352) 746-2200
(352) 746-9320
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
207ND0101X
MOHS-Micrographic Surgery Physician
—
—
207ND0900X
Dermatopathology Physician
—
—
207NS0135X
Procedural Dermatology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
377238100
—
FL
01
—
CA6816
SRRGA
FL
Enumeration date
09/01/2005
Last updated
11/15/2011
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