Basic Information
| Provider Information | |||||||||
| NPI: | 1699007484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMASURGEONS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12600 PEMBROKE ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544317681 | ||||||||
| FaxNumber: | 9544317682 | ||||||||
| Practice Location | |||||||||
| Address1: | 12600 PEMBROKE ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544317681 | ||||||||
| FaxNumber: | 9544317682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2010 | ||||||||
| LastUpdateDate: | 02/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | MENDEZ | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9544317681 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.