Healthcare Provider Details

I. General information

NPI: 1750474615
Provider Name (Legal Business Name): LAUDERDALE DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 NORTH FEDERAL HIGHWAY
FT LAUDERDALE FL
33308
US

IV. Provider business mailing address

4610 NORTH FEDERAL HIGHWAY
FT LAUDERDALE FL
33308
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-0582
  • Fax: 954-771-6465
Mailing address:
  • Phone: 954-771-0582
  • Fax: 954-771-6465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME0068188
License Number StateFL

VIII. Authorized Official

Name: GREGORY L PEREZ
Title or Position: PRESIDENT
Credential: MD
Phone: 954-771-0582