Healthcare Provider Details

I. General information

NPI: 1306957378
Provider Name (Legal Business Name): ATLANTIC DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1980 N ATLANTIC AVE SUITE 722
COCOA BEACH FL
32931-5213
US

IV. Provider business mailing address

1980 N ATLANTIC AVE SUITE 722
COCOA BEACH FL
32931-5213
US

V. Phone/Fax

Practice location:
  • Phone: 321-784-8811
  • Fax: 321-799-4424
Mailing address:
  • Phone: 321-784-8811
  • Fax: 321-799-4424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTIN WIDICK SMALLWOOD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 321-784-8811