Healthcare Provider Details

I. General information

NPI: 1861813719
Provider Name (Legal Business Name): HILLCREST DERMATOLOGY AND PLASTIC SURGERY P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2013
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 HIGHWAY 466
LADY LAKE FL
32159-6340
US

IV. Provider business mailing address

130 HILLCREST ST
ORLANDO FL
32801-1210
US

V. Phone/Fax

Practice location:
  • Phone: 407-999-2585
  • Fax: 407-999-2628
Mailing address:
  • Phone: 407-999-2585
  • Fax: 407-999-2628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberOS8467
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME73625
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME379241
License Number StateFL

VIII. Authorized Official

Name: DR. KENDRICK SPENCE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 407-999-2585