Healthcare Provider Details

I. General information

NPI: 1578955811
Provider Name (Legal Business Name): PREMIER DERMATOLOGY, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21097 NE 27TH CT SUITE 500
AVENTURA FL
33180-1204
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7176
US

V. Phone/Fax

Practice location:
  • Phone: 305-521-8971
  • Fax: 305-937-1733
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA BILU MARTIN
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 305-521-8971