Provider Demographics
NPI:1659743094
Name:INDIGO DERMATOLOGY LLC
Entity Type:Organization
Organization Name:INDIGO DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUMEET
Authorized Official - Middle Name:
Authorized Official - Last Name:THAREJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-951-1010
Mailing Address - Street 1:675 S BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1459
Mailing Address - Country:US
Mailing Address - Phone:321-951-1010
Mailing Address - Fax:321-952-4038
Practice Address - Street 1:675 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1459
Practice Address - Country:US
Practice Address - Phone:321-951-1010
Practice Address - Fax:321-952-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLID365ZMedicare PIN