Provider Demographics
NPI:1083862577
Name:EVANS DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:EVANS DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORENTINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-595-4859
Mailing Address - Street 1:902 PONDER PLACE CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3184
Mailing Address - Country:US
Mailing Address - Phone:706-922-3376
Mailing Address - Fax:706-922-5643
Practice Address - Street 1:902 PONDER PLACE CT
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3184
Practice Address - Country:US
Practice Address - Phone:706-922-3376
Practice Address - Fax:706-922-5643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0576116174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty