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General NPI Number Information
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NPI Number | 1962088138
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Entity Type | Organization
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Legal Business Name | DISTINCTIVE DERMATOLOGY PLLC
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Dates
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Enumeration Date | 03/19/2021
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Last Update Date | 04/14/2021
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Provider Practice Location Address
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Address Line | 134 E TILLMAN AVE
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City | LAKE WALES
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State | FL
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Zip | 33853-4130
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Country | US
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Telephone | 863-269-0790
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Fax |
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Provider Business Mailing Address
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Address Line | 134 E TILLMAN AVE
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City | LAKE WALES
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State | FL
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Zip | 33853-4130
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Country | US
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Telephone | 863-269-0790
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RAYMOND KNISLEY
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Credential |
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Telephone | 863-269-0790
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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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