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General NPI Number Information
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NPI Number | 1932978988
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL DERMATOLOGY ASSOCIATES
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Dates
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Enumeration Date | 01/01/2024
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Last Update Date | 01/01/2024
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Provider Practice Location Address
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Address Line | 217 E CENTRAL AVE
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City | WINTER HAVEN
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State | FL
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Zip | 33880-6312
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Country | US
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Telephone | 315-363-7407
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Fax |
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Provider Business Mailing Address
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Address Line | 4336 DUCK DOWN LN
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City | WINTER HAVEN
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State | FL
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Zip | 33884-3293
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Country | US
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Telephone | 940-867-6030
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RAYMOND R KNISLEY
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Credential | DO
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Telephone | 940-867-6030
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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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