Provider Demographics
NPI:1609863398
Name:ROMAGOSA DERMATOLOGY GROUP LLC
Entity Type:Organization
Organization Name:ROMAGOSA DERMATOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:ROMAGOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-220-3339
Mailing Address - Street 1:2220 SE OCEAN BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-2364
Mailing Address - Country:US
Mailing Address - Phone:772-220-3339
Mailing Address - Fax:772-286-2635
Practice Address - Street 1:2220 SE OCEAN BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-2364
Practice Address - Country:US
Practice Address - Phone:772-220-3339
Practice Address - Fax:772-286-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85844207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79738OtherBCBS
FLH86716Medicare UPIN
FL79738ZMedicare ID - Type Unspecified