Provider Demographics
NPI:1558450908
Name:HIALEAH DERMATOLOGY AND COSMETIC CENTER LLC
Entity Type:Organization
Organization Name:HIALEAH DERMATOLOGY AND COSMETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:EDDIE
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-822-0678
Mailing Address - Street 1:7000 W 12TH AVE
Mailing Address - Street 2:SUITE#4
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-5154
Mailing Address - Country:US
Mailing Address - Phone:305-822-0678
Mailing Address - Fax:305-822-0698
Practice Address - Street 1:7000 W 12TH AVE
Practice Address - Street 2:SUITE#4
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-5154
Practice Address - Country:US
Practice Address - Phone:305-822-0678
Practice Address - Fax:305-822-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6127207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS6127OtherMEDICAL LICENSE NUMBER
FL600471-7OtherOCCUPATIONAL LICENSE
FLBV9690670OtherDEA NUMBER