1568135507 NPI number — ADULT AND PEDIATRIC DERMATOLOGY PRACTITIONERS P A

Table of content: (NPI 1568135507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568135507 NPI number — ADULT AND PEDIATRIC DERMATOLOGY PRACTITIONERS P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADULT AND PEDIATRIC DERMATOLOGY PRACTITIONERS P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568135507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 GREEN POND RD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKAWAY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07866-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-625-0600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13005 SOUTHERN BLVD STE 224
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOXAHATCHEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33470-9272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-793-2929
Provider Business Practice Location Address Fax Number:
561-790-7568
Provider Enumeration Date:
07/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MASESSA
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-625-0600

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MA851 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 111532006 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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