MEDICARE: LINA S PLANTILLA MD, FAAD

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	207N00000X	Dermatology Physician	74802680507	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29246	OTHER	NY	BCBS
2	0043457	OTHER	NY	GHI

General Provider Information

NPI Number	:	1306845599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINA S PLANTILLA MD, FAAD

Provider Business Mailing Address
First Line	:	2514 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3916
Country	:	US
Telephone Number	:	718-934-7373
Fax Number	:	718-648-9548

Provider Business Practice Location Address
First Line	:	2514 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3916
Country	:	US
Telephone Number	:	718-934-7373
Fax Number	:	718-648-9548

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	10/07/2010

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