Provider Demographics
NPI:1306845599
Name:PLANTILLA, LINA S (MD, FAAD)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:S
Last Name:PLANTILLA
Suffix:
Gender:F
Credentials:MD, FAAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3916
Mailing Address - Country:US
Mailing Address - Phone:718-934-7373
Mailing Address - Fax:718-648-9548
Practice Address - Street 1:2514 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3916
Practice Address - Country:US
Practice Address - Phone:718-934-7373
Practice Address - Fax:718-648-9548
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY74802680507207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY29246OtherBCBS
NY0043457OtherGHI
B12401Medicare UPIN
NY0043457OtherGHI