Healthcare Provider Details

I. General information

NPI: 1730956855
Provider Name (Legal Business Name): PREMIER DERMATOLOGY ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CORAL RIDGE DR CARDIOVASCULAR SUITES
CORAL SPRINGS FL
33071-4180
US

IV. Provider business mailing address

214 AMHERST ST
BROOKLYN NY
11235-4117
US

V. Phone/Fax

Practice location:
  • Phone: 305-810-8846
  • Fax:
Mailing address:
  • Phone: 917-804-4553
  • Fax: 917-975-6272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ARKADY KALYUZHNY
Title or Position: PRESIDENT
Credential:
Phone: 917-804-4553