=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013401710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCEANS DERMATOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2018
-----------------------------------------------------
Last Update Date | 08/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10151 ENTERPRISE CENTER BLVD SUITE 204
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-235-4222
-----------------------------------------------------
Fax | 561-737-8583
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10151 ENTERPRISE CENTER BLVD SUITE 204
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-405-3000
-----------------------------------------------------
Fax | 561-459-1444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TEO D DAMSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-405-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------