Provider Demographics
NPI:1588195721
Name:CONDE DERMATOLOGY GROUP PLLC
Entity Type:Organization
Organization Name:CONDE DERMATOLOGY GROUP PLLC
Other - Org Name:CONDE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MOSCOSO
Authorized Official - Last Name:CONDE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-530-6511
Mailing Address - Street 1:5627 SKYTOP DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5607 SKYTOP DRIVE
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547
Practice Address - Country:US
Practice Address - Phone:813-530-6511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12902261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center