Provider Demographics
NPI:1548411077
Name:FT. LAUDERDALE DERMATOLOGY & COSMETIC CENTER
Entity Type:Organization
Organization Name:FT. LAUDERDALE DERMATOLOGY & COSMETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-772-0416
Mailing Address - Street 1:5721 NE 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2703
Mailing Address - Country:US
Mailing Address - Phone:954-772-0416
Mailing Address - Fax:
Practice Address - Street 1:5721 NE 27TH AVE
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2703
Practice Address - Country:US
Practice Address - Phone:954-772-0416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty