Basic Information
| Provider Information | |||||||||
| NPI: | 1689815904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY CONSULTANTS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12600 PEMBROKE RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330272544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544317681 | ||||||||
| FaxNumber: | 9544317682 | ||||||||
| Practice Location | |||||||||
| Address1: | 12600 PEMBROKE RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330272544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544317681 | ||||||||
| FaxNumber: | 9544317682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | MENDEZ | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9544317681 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 11/17/2020 | ||||||||
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 | 022844800 | 05 | FL | MEDICAID |