Healthcare Provider Details

I. General information

NPI: 1174078281
Provider Name (Legal Business Name): DERMATOLOGY AND SKIN CANCER SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7560 RED BUG LAKE RD STE 1014
OVIEDO FL
32765-6591
US

IV. Provider business mailing address

7560 RED BUG LAKE RD STE 1014
OVIEDO FL
32765-6591
US

V. Phone/Fax

Practice location:
  • Phone: 407-706-1770
  • Fax:
Mailing address:
  • Phone: 407-706-1770
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: VITALY BLATNOY
Title or Position: OWNER
Credential: MD
Phone: 407-706-1770