Healthcare Provider Details

I. General information

NPI: 1043900947
Provider Name (Legal Business Name): ORLANDO DERMATOLOGY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 ALDER AVE
MIDDLETON FL
34762-6162
US

IV. Provider business mailing address

1040 LAKE SUMTER LNDG
THE VILLAGES FL
32162-2697
US

V. Phone/Fax

Practice location:
  • Phone: 352-218-3211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: TAREK S SHAATH
Title or Position: OWNER
Credential:
Phone: 352-218-3211