Provider Demographics
NPI:1467623249
Name:ADULT AND PEDIATRIC DERMATOLOGY PC
Entity Type:Organization
Organization Name:ADULT AND PEDIATRIC DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SUMMA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-364-2626
Mailing Address - Street 1:1078 OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-1941
Mailing Address - Country:US
Mailing Address - Phone:516-442-0133
Mailing Address - Fax:516-442-0131
Practice Address - Street 1:1078 OAKS DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-1941
Practice Address - Country:US
Practice Address - Phone:516-442-0133
Practice Address - Fax:516-442-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2338781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WZT7H1Medicare PIN