Basic Information
| Provider Information | |||||||||
| NPI: | 1174078281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY AND SKIN CANCER SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7250 RED BUG LAKE RD STE 1020 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327659290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077061770 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 7250 RED BUG LAKE RD STE 1020 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077061770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2016 | ||||||||
| LastUpdateDate: | 06/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | BLATNOY | ||||||||
| AuthorizedOfficialFirstName: | VITALY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4077061770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 001633600 | 05 | FL | MEDICAID |