Basic Information
| Provider Information | |||||||||
| NPI: | 1477853125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTSIDE DERMATOLOGY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5353 N FEDERAL HWY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333083245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544899800 | ||||||||
| FaxNumber: | 9544890401 | ||||||||
| Practice Location | |||||||||
| Address1: | 5353 N FEDERAL HWY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333083245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544899800 | ||||||||
| FaxNumber: | 9544890401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2010 | ||||||||
| LastUpdateDate: | 10/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | CHAPLIK | ||||||||
| AuthorizedOfficialFirstName: | IGOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9544899800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 800002278 | FL | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.