MEDICARE: CLEARLY DERM, LLC

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	174400000X	Specialist	ME42065	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10453	OTHER	FL	HCC
2	HCC9614	OTHER	FL	STAE LICENSE
3	HCC9613	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1487947008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEARLY DERM, LLC

Provider Business Mailing Address
First Line	:	7050 W PALMETTO PARK RD
Second Line	:	SUITE 30
City	:	BOCA RATON
State	:	FL
Zip	:	33433-3426
Country	:	US
Telephone Number	:	561-353-3376
Fax Number	:	561-404-1170

Provider Business Practice Location Address
First Line	:	1760 N CONGRESS AVE
Second Line	:	SUITE 200
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8214
Country	:	US
Telephone Number	:	561-739-9595
Fax Number	:	561-739-7546

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	ANDREA COLTON
Credential	:	MD
Telephone Number	:	561-299-3907

Provider Enumeration Date	:	05/17/2011
Last Update Date	:	07/13/2016

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Directions to “CLEARLY DERM, LLC ” Practice Location

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