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General NPI Number Information
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NPI Number | 1235938341
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Entity Type | Organization
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Legal Business Name | LUMEN DERMATOLOGY LLC
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Dates
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Enumeration Date | 03/11/2025
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Last Update Date | 03/16/2025
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Provider Practice Location Address
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Address Line | 781 HIGHWAY 466
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City | LADY LAKE
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State | FL
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Zip | 32159-6340
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Country | US
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Telephone | 352-830-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 4365 SE 15TH AVE
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City | OCALA
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State | FL
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Zip | 34480-6613
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Country | US
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Telephone | 352-598-5763
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAVID J KOSIOREK
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Credential | PA-C
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Telephone | 813-598-9837
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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