Healthcare Provider Details

I. General information

NPI: 1316522691
Provider Name (Legal Business Name): REJUVA DERMATOLOGY & VEIN CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 09/02/2025
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 COMMERCIAL CT STE C
VENICE FL
34292-1651
US

IV. Provider business mailing address

2389 E VENICE AVE UNIT 510
VENICE FL
34292-2465
US

V. Phone/Fax

Practice location:
  • Phone: 941-529-0070
  • Fax: 941-529-0539
Mailing address:
  • Phone: 941-529-0070
  • Fax: 941-529-0539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GOLTA RASOULI
Title or Position: CO-PRESENDENT
Credential: MD
Phone: 941-529-0070