Healthcare Provider Details

I. General information

NPI: 1487042636
Provider Name (Legal Business Name): ELIAS DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E COMMERCIAL BLVD
FORT LAUDERDALE FL
33308-4327
US

IV. Provider business mailing address

3100 E COMMERCIAL BLVD
FORT LAUDERDALE FL
33308-4327
US

V. Phone/Fax

Practice location:
  • Phone: 415-802-1310
  • Fax: 954-771-0582
Mailing address:
  • Phone: 415-802-1310
  • Fax: 954-771-0582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS9756
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberOS9756
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberOS9756
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberOS9756
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberOS9756
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberOS9756
License Number StateFL

VIII. Authorized Official

Name: DR. MATTHEW J ELIAS
Title or Position: MANAGER MEMBER
Credential: D.O.
Phone: 415-802-1310