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NPI Code Detail

MEDICARE: INTEGRATED DERMATOLOGY OF PONCHATOULA, LLC

MEDICARE: INTEGRATED DERMATOLOGY OF PONCHATOULA, 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
1207N00000XDermatology Physician

General Provider Information

NPI Number : 1508234600
Entity Type Code : Organization
Provider Name (Legal Business Name) : INTEGRATED DERMATOLOGY OF PONCHATOULA, LLC
Provider Business Mailing Address
First Line : 4700 EXCHANGE CT STE 110
Second Line :
City : BOCA RATON
State : FL
Zip : 33431-4450
Country : US
Telephone Number : 561-314-2000
Fax Number :
Provider Business Practice Location Address
First Line : 180 N 5TH ST
Second Line :
City : PONCHATOULA
State : LA
Zip : 70454-2532
Country : US
Telephone Number : 985-370-7546
Fax Number :
Authorized Official
Title or Position : MANAGER
Name : JEFFREY QUEEN
Credential :
Telephone Number : 561-314-2000
Provider Enumeration Date : 09/04/2015
Last Update Date : 05/21/2019

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