Healthcare Provider Details

I. General information

NPI: 1144637364
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF TAMPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15310 AMBERLY DR SUITE 150
TAMPA FL
33647-2199
US

IV. Provider business mailing address

902 CLINT MOORE RD SUITE 226
BOCA RATON FL
33487-2800
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-8888
  • Fax: 813-972-8974
Mailing address:
  • Phone: 561-314-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY QUEEN
Title or Position: MANAGER
Credential:
Phone: 561-314-2000