Basic Information
| Provider Information | |||||||||
| NPI: | 1669622452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVENTURA DERMATOLOGY & COSMETIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21097 NE 27TH CT | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059316661 | ||||||||
| FaxNumber: | 3059371733 | ||||||||
| Practice Location | |||||||||
| Address1: | 21097 NE 27TH CT | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059316661 | ||||||||
| FaxNumber: | 3059371733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 09/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3059316661 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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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.