Provider Demographics
NPI:1508172594
Name:LAYNE D. NISENBAUM, DO, PA
Entity Type:Organization
Organization Name:LAYNE D. NISENBAUM, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAYNE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NISENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-832-1950
Mailing Address - Street 1:50 COCOANUT ROW
Mailing Address - Street 2:SUITE #120
Mailing Address - City:PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33480-4025
Mailing Address - Country:US
Mailing Address - Phone:561-832-1950
Mailing Address - Fax:561-832-1926
Practice Address - Street 1:50 COCOANUT ROW
Practice Address - Street 2:SUITE #120
Practice Address - City:PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33480-4025
Practice Address - Country:US
Practice Address - Phone:561-832-1950
Practice Address - Fax:561-832-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006028207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE26306Medicare UPIN