Healthcare Provider Details

I. General information

NPI: 1053779223
Provider Name (Legal Business Name): EXQUISITE DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12315 LAKE UNDERHILL RD
ORLANDO FL
32828-4507
US

IV. Provider business mailing address

12315 LAKE UNDERHILL RD
ORLANDO FL
32828-4507
US

V. Phone/Fax

Practice location:
  • Phone: 407-403-5620
  • Fax: 407-412-5920
Mailing address:
  • Phone: 407-403-5620
  • Fax: 407-412-5920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME109349
License Number StateDE

VIII. Authorized Official

Name: MRS. LOUISE M CLINGMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 407-459-5213