Healthcare Provider Details

I. General information

NPI: 1821909714
Provider Name (Legal Business Name): SKIN DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 A1A N STE 200
PONTE VEDRA BEACH FL
32082-5701
US

IV. Provider business mailing address

166 A1A N STE 200
PONTE VEDRA BEACH FL
32082-5701
US

V. Phone/Fax

Practice location:
  • Phone: 253-226-2798
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MITCHELL BRADY
Title or Position: OWNER
Credential: DO
Phone: 253-226-2798