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NPI Code Detail

MEDICARE: OPTIMA DERMATOLOGY LLC

MEDICARE: OPTIMA DERMATOLOGY 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
1207ND0101XMOHS-Micrographic Surgery Physician
2207ND0900XDermatopathology Physician
3207ZP0101XAnatomic Pathology Physician
4174400000XSpecialist
5207N00000XDermatology Physician

General Provider Information

NPI Number : 1831187764
Entity Type Code : Organization
Provider Name (Legal Business Name) : OPTIMA DERMATOLOGY LLC
Provider Business Mailing Address
First Line : 111 NEW HAMPSHIRE AVE STE 2
Second Line :
City : PORTSMOUTH
State : NH
Zip : 03801-2864
Country : US
Telephone Number : 802-909-2053
Fax Number : 330-965-9325
Provider Business Practice Location Address
First Line : 987 BOARDMAN CANFIELD RD
Second Line :
City : BOARDMAN
State : OH
Zip : 44512-4222
Country : US
Telephone Number : 330-965-8760
Fax Number : 330-965-9325
Authorized Official
Title or Position : AUTHORIZED OFFICIAL
Name : JOHN BERNAT
Credential : MD
Telephone Number : 330-965-8760
Provider Enumeration Date : 10/13/2005
Last Update Date : 07/01/2024

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Directions to “OPTIMA DERMATOLOGY LLC ” Practice Location

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