Provider Demographics
NPI:1245751403
Name:BLUEWATER DERMATOLOGY AND SKIN CANCER CENTER PA
Entity Type:Organization
Organization Name:BLUEWATER DERMATOLOGY AND SKIN CANCER CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRAZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-640-0899
Mailing Address - Street 1:144 POOLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9504
Mailing Address - Country:US
Mailing Address - Phone:910-262-1048
Mailing Address - Fax:910-256-6039
Practice Address - Street 1:144 POOLE RD STE 101
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-9504
Practice Address - Country:US
Practice Address - Phone:910-262-1048
Practice Address - Fax:910-256-6039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00516207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty