Provider Demographics
NPI:1619746799
Name:MEDICAL AESTHETICS OF FLORIDA
Entity Type:Organization
Organization Name:MEDICAL AESTHETICS OF FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMETRIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-446-8485
Mailing Address - Street 1:155 FOUNTAINS WAY STE 11
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 FOUNTAINS WAY STE 11
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1144
Practice Address - Country:US
Practice Address - Phone:904-561-1772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center