Provider Demographics
NPI:1427180645
Name:FLORIDA DERMATOLOGIC SURGERY & AESTHETICS INSTITUTE PA
Entity Type:Organization
Organization Name:FLORIDA DERMATOLOGIC SURGERY & AESTHETICS INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHRAF
Authorized Official - Middle Name:M
Authorized Official - Last Name:HASSANEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-430-2580
Mailing Address - Street 1:11950 COUNTY ROAD 101
Mailing Address - Street 2:SUITE 203
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-9332
Mailing Address - Country:US
Mailing Address - Phone:352-430-2580
Mailing Address - Fax:352-430-2651
Practice Address - Street 1:11950 COUNTY ROAD 101
Practice Address - Street 2:SUITE 203
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-9332
Practice Address - Country:US
Practice Address - Phone:352-430-2580
Practice Address - Fax:352-430-2651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68908OtherBCBS FL
FL68908OtherBCBS FL