Healthcare Provider Details

I. General information

NPI: 1831187764
Provider Name (Legal Business Name): OPTIMA DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

987 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4222
US

IV. Provider business mailing address

111 NEW HAMPSHIRE AVE STE 2
PORTSMOUTH NH
03801-2864
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-8760
  • Fax: 330-965-9325
Mailing address:
  • Phone: 802-909-2053
  • Fax: 330-965-9325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN BERNAT
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 330-965-8760