Provider Demographics
NPI:1033752969
Name:FAMILY DERMATOLOGY OF NORTH FLORIDA LLC
Entity Type:Organization
Organization Name:FAMILY DERMATOLOGY OF NORTH FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:OEN-HIANG
Authorized Official - Middle Name:CYNTHIA
Authorized Official - Last Name:TIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-402-9444
Mailing Address - Street 1:1981 CAPITAL CIR NE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4421
Mailing Address - Country:US
Mailing Address - Phone:850-402-9444
Mailing Address - Fax:850-402-0188
Practice Address - Street 1:1981 CAPITAL CIR NE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4421
Practice Address - Country:US
Practice Address - Phone:850-402-9444
Practice Address - Fax:850-402-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257072600Medicaid
FL46953OtherBCBS