Healthcare Provider Details

I. General information

NPI: 1114769767
Provider Name (Legal Business Name): LUMINARY DERMATOLOGY OF MIAMI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8740 N KENDALL DR STE 101
MIAMI FL
33176-2209
US

IV. Provider business mailing address

4411 BEE RIDGE RD # 309
SARASOTA FL
34233-2514
US

V. Phone/Fax

Practice location:
  • Phone: 305-661-8978
  • Fax: 941-296-8501
Mailing address:
  • Phone: 941-926-6553
  • Fax: 941-296-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSICA PHILLIPS
Title or Position: CEO
Credential:
Phone: 941-926-6553