MEDICARE: ELLIS J GOTTESFELD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician	ME72007	FL
2	207ND0101X	MOHS-Micrographic Surgery Physician	ME72007	FL
3	207NP0225X	Pediatric Dermatology Physician	ME72007	FL
4	207N00000X	Dermatology Physician	ME 72007	FL

General Provider Information

NPI Number	:	1255356119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLIS J GOTTESFELD MD

Provider Business Mailing Address
First Line	:	7730 BOYNTON BEACH BLVD
Second Line	:	#4
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-6155
Country	:	US
Telephone Number	:	561-572-0299
Fax Number	:	561-572-2596

Provider Business Practice Location Address
First Line	:	7730 BOYNTON BEACH BLVD
Second Line	:	#4
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-6155
Country	:	US
Telephone Number	:	561-572-0299
Fax Number	:	561-572-2596

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	10/28/2013

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Directions to “ ELLIS J GOTTESFELD MD” Practice Location

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