Provider Demographics
NPI:1568135507
Name:ADULT AND PEDIATRIC DERMATOLOGY PRACTITIONERS P A
Entity Type:Organization
Organization Name:ADULT AND PEDIATRIC DERMATOLOGY PRACTITIONERS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MASESSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-625-0600
Mailing Address - Street 1:35 GREEN POND RD STE C
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-2057
Mailing Address - Country:US
Mailing Address - Phone:973-625-0600
Mailing Address - Fax:
Practice Address - Street 1:13005 SOUTHERN BLVD STE 224
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9272
Practice Address - Country:US
Practice Address - Phone:561-793-2929
Practice Address - Fax:561-790-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA851OtherMEDICARE