Healthcare Provider Details

I. General information

NPI: 1174390926
Provider Name (Legal Business Name): CARDINAL DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 01/02/2025
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4322 LAFAYETTE BLVD
SOUTH BEND IN
46614
US

IV. Provider business mailing address

4322 S LAFAYETTE BLVD
SOUTH BEND IN
46614-2189
US

V. Phone/Fax

Practice location:
  • Phone: 574-391-1111
  • Fax:
Mailing address:
  • Phone: 574-391-1111
  • Fax: 574-859-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LUIZ CARLOS PANTALENA FILHO
Title or Position: MEMBER
Credential: MD, PHD
Phone: 650-387-9765