Healthcare Provider Details

I. General information

NPI: 1659743094
Provider Name (Legal Business Name): INDIGO DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 07/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 S BABCOCK ST
MELBOURNE FL
32901-1459
US

IV. Provider business mailing address

675 S BABCOCK ST
MELBOURNE FL
32901-1459
US

V. Phone/Fax

Practice location:
  • Phone: 321-951-1010
  • Fax: 321-952-4038
Mailing address:
  • Phone: 321-951-1010
  • Fax: 321-952-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME123157
License Number StateFL

VIII. Authorized Official

Name: SUMEET THAREJA
Title or Position: OWNER
Credential: M.D.
Phone: 321-951-1010