Provider Demographics
NPI:1225101231
Name:AESTHETIC DERMATOLOGY PA
Entity Type:Organization
Organization Name:AESTHETIC DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAD
Authorized Official - Phone:352-267-0146
Mailing Address - Street 1:210 NORTH HIGHWAY 27
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711
Mailing Address - Country:US
Mailing Address - Phone:352-243-2544
Mailing Address - Fax:352-243-2745
Practice Address - Street 1:210 N HIGHWAY 27 STE 1
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2411
Practice Address - Country:US
Practice Address - Phone:352-243-2544
Practice Address - Fax:352-243-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70658207N00000X
207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011965400Medicaid
FL011965403Medicaid