MEDICARE: MIAMI DERMATOLOGY AND AESTHETIC CENTER, 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

General Provider Information

NPI Number	:	1760737472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIAMI DERMATOLOGY AND AESTHETIC CENTER, LLC

Provider Business Mailing Address
First Line	:	8501 SW 124TH AVENUE
Second Line	:	SUITE 203-B
City	:	MIAMI
State	:	FL
Zip	:	33183-4634
Country	:	US
Telephone Number	:	786-953-8198
Fax Number	:	786-953-8254

Provider Business Practice Location Address
First Line	:	8501 SW 124TH AVENUE
Second Line	:	SUITE 203-B
City	:	MIAMI
State	:	FL
Zip	:	33183-4634
Country	:	US
Telephone Number	:	786-953-8198
Fax Number	:	786-953-8254

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	REBECCA IBANEZ
Credential	:
Telephone Number	:	786-953-8198

Provider Enumeration Date	:	07/18/2012
Last Update Date	:	07/18/2012

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