Provider Demographics
NPI:1528181310
Name:INTEGRATED DERMATOLOGY OF WEST BROWARD LLC
Entity Type:Organization
Organization Name:INTEGRATED DERMATOLOGY OF WEST BROWARD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-241-6676
Mailing Address - Street 1:951 BROKEN SOUND PKWY NW
Mailing Address - Street 2:STE 115
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-3507
Mailing Address - Country:US
Mailing Address - Phone:561-241-6676
Mailing Address - Fax:
Practice Address - Street 1:8035 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-1116
Practice Address - Country:US
Practice Address - Phone:561-241-6676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty