Provider Demographics
NPI:1477853125
Name:EASTSIDE DERMATOLOGY, PA
Entity Type:Organization
Organization Name:EASTSIDE DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPLIK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-489-9800
Mailing Address - Street 1:5353 N FEDERAL HWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3245
Mailing Address - Country:US
Mailing Address - Phone:954-489-9800
Mailing Address - Fax:954-489-0401
Practice Address - Street 1:5353 N FEDERAL HWY
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3245
Practice Address - Country:US
Practice Address - Phone:954-489-9800
Practice Address - Fax:954-489-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800002278291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory