Provider Demographics
NPI:1538465075
Name:SOUTH FLORIDA DERMATOLOGY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SOUTH FLORIDA DERMATOLOGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-971-1210
Mailing Address - Street 1:12600 SW 120TH ST STE 113
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-9116
Mailing Address - Country:US
Mailing Address - Phone:305-971-1210
Mailing Address - Fax:305-971-7710
Practice Address - Street 1:12600 SW 120TH ST STE 113
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-9116
Practice Address - Country:US
Practice Address - Phone:305-971-1210
Practice Address - Fax:305-971-7710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104674900Medicaid