Provider Demographics
NPI:1376230581
Name:MODERN DERMATOLOGY AND COSMETIC CENTER LLC
Entity Type:Organization
Organization Name:MODERN DERMATOLOGY AND COSMETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HATZIMINAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-391-1694
Mailing Address - Street 1:2510 BELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2510 BELMAR BLVD
Practice Address - Street 2:
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719-3948
Practice Address - Country:US
Practice Address - Phone:908-391-1694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty