Healthcare Provider Details

I. General information

NPI: 1295278943
Provider Name (Legal Business Name): FLORIDA DERMATOLOGY PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6559 N WICKHAM RD SUITE 105
MELBOURNE FL
32940-2039
US

IV. Provider business mailing address

PO BOX 628721
ORLANDO FL
32862-8721
US

V. Phone/Fax

Practice location:
  • Phone: 321-345-0552
  • Fax:
Mailing address:
  • Phone: 321-241-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM82777
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME118444
License Number StateFL

VIII. Authorized Official

Name: ANITA SALUJA
Title or Position: MANAGER
Credential: M.D.
Phone: 321-917-3067