Provider Demographics
NPI:1437545472
Name:CLERMONT INTERNAL AND COSMETIC MEDICINE LLC
Entity Type:Organization
Organization Name:CLERMONT INTERNAL AND COSMETIC MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED REP
Authorized Official - Prefix:
Authorized Official - First Name:EDRISS
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTIME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-404-5174
Mailing Address - Street 1:290 CITRUS TOWER BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2783
Mailing Address - Country:US
Mailing Address - Phone:352-404-5174
Mailing Address - Fax:352-678-3430
Practice Address - Street 1:290 CITRUS TOWER BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2783
Practice Address - Country:US
Practice Address - Phone:352-404-5174
Practice Address - Fax:352-678-3430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014748100Medicaid
FL014748100Medicaid