Basic Information
| Provider Information | |||||||||
| NPI: | 1548411077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FT. LAUDERDALE DERMATOLOGY & COSMETIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5721 NE 27TH AVE | ||||||||
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| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333082703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547720416 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5721 NE 27TH AVE | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333082703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547720416 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | BRADLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9547720416 | ||||||||
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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 | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.