Healthcare Provider Details

I. General information

NPI: 1891257655
Provider Name (Legal Business Name): ORLANDO DERMATOLOGY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 LAKE SUMTER LNDG
THE VILLAGES FL
32162-2697
US

IV. Provider business mailing address

697 OAK HOLLOW WAY
ALTAMONTE SPRINGS FL
32714-1838
US

V. Phone/Fax

Practice location:
  • Phone: 352-218-3211
  • Fax: 877-699-3709
Mailing address:
  • Phone: 785-760-6740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TAREK SAMIR SHAATH
Title or Position: DERMATOLOGIST, LLC PRESIDENT
Credential: MD
Phone: 785-760-6740