Healthcare Provider Details

I. General information

NPI: 1669622452
Provider Name (Legal Business Name): AVENTURA DERMATOLOGY & COSMETIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 09/29/2008
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

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

V. Phone/Fax

Practice location:
  • Phone: 305-931-6661
  • Fax: 305-937-1733
Mailing address:
  • Phone: 305-931-6661
  • Fax: 305-937-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JASON GREEN
Title or Position: OWNER / PRESIDENT
Credential: DO
Phone: 305-931-6661