Healthcare Provider Details

I. General information

NPI: 1538879267
Provider Name (Legal Business Name): PATIENT AND DERM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 RED BUG LAKE RD STE 1020
OVIEDO FL
32765-9290
US

IV. Provider business mailing address

115 E CONCORD ST UNIT 1
ORLANDO FL
32801-1337
US

V. Phone/Fax

Practice location:
  • Phone: 407-706-1770
  • Fax: 407-706-1777
Mailing address:
  • Phone: 610-529-0666
  • Fax: 321-319-9714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MIKHAIL VAYSBERG
Title or Position: OWNER
Credential:
Phone: 610-529-0666