Provider Demographics
NPI:1184501611
Name:BLUE OCEAN DERAMTOLOGY LLC
Entity type:Organization
Organization Name:BLUE OCEAN DERAMTOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NITRA
Authorized Official - Middle Name:HOBBS
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:386-256-1444
Mailing Address - Street 1:3951 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9270
Mailing Address - Country:US
Mailing Address - Phone:386-256-1444
Mailing Address - Fax:321-400-1118
Practice Address - Street 1:105 N DUSS ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6971
Practice Address - Country:US
Practice Address - Phone:386-256-1444
Practice Address - Fax:321-400-1118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE OCEAN DERAMTOLOGY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty