Healthcare Provider Details

I. General information

NPI: 1487093316
Provider Name (Legal Business Name): COMPREHENSIVE DERMATOLOGY AND DERMATOLOGIC SURGERY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N LAKEMONT AVE SUITE 100
WINTER PARK FL
32792-3228
US

IV. Provider business mailing address

201 N LAKEMONT AVE SUITE 100
WINTER PARK FL
32792-3228
US

V. Phone/Fax

Practice location:
  • Phone: 407-339-7546
  • Fax:
Mailing address:
  • Phone: 407-339-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME105564
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME105564
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME105564
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME105587
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberME105587
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberME105587
License Number StateFL

VIII. Authorized Official

Name: MRS. YVETTE MEJIA
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 407-339-7546