Healthcare Provider Details

I. General information

NPI: 1164165296
Provider Name (Legal Business Name): INSTITUTE OF DERMATOLOGY & OCULOPLASTIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 S TUTTLE AVE FL 3
SARASOTA FL
34239-3132
US

IV. Provider business mailing address

PO BOX 15853
SARASOTA FL
34277-1853
US

V. Phone/Fax

Practice location:
  • Phone: 941-499-0199
  • Fax: 941-200-4021
Mailing address:
  • Phone: 941-499-0199
  • Fax: 941-200-4021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ILYA LIM
Title or Position: CO-OWNER
Credential: MD
Phone: 941-499-0199