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NPI Code Detail

MEDICARE: ORLANDO DERMATOLOGY CLINIC LLC

MEDICARE: ORLANDO DERMATOLOGY CLINIC 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 : 1669251112
Entity Type Code : Organization
Provider Name (Legal Business Name) : ORLANDO DERMATOLOGY CLINIC LLC
Provider Business Mailing Address
First Line : 1040 LAKE SUMTER LNDG
Second Line :
City : THE VILLAGES
State : FL
Zip : 32162-2697
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 118 W ORANGE ST
Second Line :
City : ALTAMONTE SPRINGS
State : FL
Zip : 32714-2537
Country : US
Telephone Number : 352-218-3211
Fax Number :
Authorized Official
Title or Position : MD
Name : TAREK S SHAATH
Credential :
Telephone Number : 352-218-3211
Provider Enumeration Date : 09/25/2023
Last Update Date : 02/01/2024

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Directions to “ORLANDO DERMATOLOGY CLINIC LLC ” Practice Location

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