=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760504682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANDON DERMATOLOGY P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 09/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 W BLOOMINGDALE AVE
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-7401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-662-3376
-----------------------------------------------------
Fax | 813-662-3009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 W BLOOMINGDALE AVE
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-7401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-662-3376
-----------------------------------------------------
Fax | 813-662-3009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENTPHYSICIAN
-----------------------------------------------------
Name | ANDRES TOBON
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 813-662-3376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | OS7868
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------