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General NPI Number Information
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NPI Number | 1174390926
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Entity Type | Organization
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Legal Business Name | CARDINAL DERMATOLOGY LLC
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Dates
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Enumeration Date | 12/11/2023
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Last Update Date | 01/02/2025
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Provider Practice Location Address
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Address Line | 4322 LAFAYETTE BLVD
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City | SOUTH BEND
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State | IN
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Zip | 46614
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Country | US
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Telephone | 574-391-1111
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Fax |
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Provider Business Mailing Address
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Address Line | 4322 S LAFAYETTE BLVD
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City | SOUTH BEND
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State | IN
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Zip | 46614-2189
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Country | US
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Telephone | 574-391-1111
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Fax | 574-859-5040
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Authorized Official
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Title or Position | MEMBER
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Name | LUIZ CARLOS PANTALENA FILHO
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Credential | MD, PHD
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Telephone | 650-387-9765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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