Provider Demographics
NPI:1639125735
Name:ADVANCED DERMATOLOGIC & COSMETIC INSTITUTE INC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGIC & COSMETIC INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRDJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRODANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-598-3200
Mailing Address - Street 1:90 CYPRESS WAY E
Mailing Address - Street 2:SUITE 50
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-9275
Mailing Address - Country:US
Mailing Address - Phone:239-598-3200
Mailing Address - Fax:239-598-0233
Practice Address - Street 1:90 CYPRESS WAY E
Practice Address - Street 2:SUITE 50
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-9275
Practice Address - Country:US
Practice Address - Phone:239-598-3200
Practice Address - Fax:239-598-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME95851207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDG2330OtherMEDICARE RAILROAD
FLQ0489Medicare PIN