Provider Demographics
NPI:1598257909
Name:PARK NORTH DERMATOLOGY, PA
Entity Type:Organization
Organization Name:PARK NORTH DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-399-7878
Mailing Address - Street 1:343 SAINT DUNSTAN WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4306
Mailing Address - Country:US
Mailing Address - Phone:407-399-7878
Mailing Address - Fax:
Practice Address - Street 1:341 N MAITLAND AVE STE 210
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4771
Practice Address - Country:US
Practice Address - Phone:407-603-1748
Practice Address - Fax:586-580-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty