Provider Demographics
NPI:1477906857
Name:WATER'S EDGE DERMATOLOGY
Entity Type:Organization
Organization Name:WATER'S EDGE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-693-0540
Mailing Address - Street 1:2845 PGA BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2910
Mailing Address - Country:US
Mailing Address - Phone:561-693-0540
Mailing Address - Fax:561-422-4212
Practice Address - Street 1:7605 CONROY WINDERMERE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-2646
Practice Address - Country:US
Practice Address - Phone:561-693-0540
Practice Address - Fax:561-422-4212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty