Provider Demographics
NPI:1760504682
Name:BRANDON DERMATOLOGY P A
Entity Type:Organization
Organization Name:BRANDON DERMATOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTPHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:TOBON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-662-3376
Mailing Address - Street 1:405 W BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7401
Mailing Address - Country:US
Mailing Address - Phone:813-662-3376
Mailing Address - Fax:813-662-3009
Practice Address - Street 1:405 W BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7401
Practice Address - Country:US
Practice Address - Phone:813-662-3376
Practice Address - Fax:813-662-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7868207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL785OtherMEDICARE PTAN