Provider Demographics
NPI:1073577136
Name:FLORIDA DERMATOLOGY ASSOCIATES INC
Entity Type:Organization
Organization Name:FLORIDA DERMATOLOGY ASSOCIATES INC
Other - Org Name:PALM BAY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-768-1600
Mailing Address - Street 1:5070 MINTON RD NW
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1157
Mailing Address - Country:US
Mailing Address - Phone:321-768-1600
Mailing Address - Fax:321-799-4903
Practice Address - Street 1:5070 MINTON RD NW
Practice Address - Street 2:SUITE 5
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1157
Practice Address - Country:US
Practice Address - Phone:321-768-1600
Practice Address - Fax:321-768-6418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51282207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070002166AOtherRAILROAD MEDICARE
FL94928OtherBCBS
FL169940OtherWELLCARE
FL169940OtherWELLCARE