Provider Demographics
NPI:1376714162
Name:DERMATOLOGY ADVANCED CARE, P.A.
Entity Type:Organization
Organization Name:DERMATOLOGY ADVANCED CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BREWSTER
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-219-8811
Mailing Address - Street 1:2433 MAHAN DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5329
Mailing Address - Country:US
Mailing Address - Phone:850-219-8811
Mailing Address - Fax:850-219-8883
Practice Address - Street 1:2433 MAHAN DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5329
Practice Address - Country:US
Practice Address - Phone:850-219-8811
Practice Address - Fax:850-219-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7111207N00000X
MASTER ID 8538207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG24779Medicare UPIN