Provider Demographics
NPI:1760810816
Name:MEDICAL AESTHETIC ARTS
Entity Type:Organization
Organization Name:MEDICAL AESTHETIC ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ABNER
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:727-586-0545
Mailing Address - Street 1:2520 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-1935
Mailing Address - Country:US
Mailing Address - Phone:727-586-0545
Mailing Address - Fax:727-586-0547
Practice Address - Street 1:2520 W BAY DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-1935
Practice Address - Country:US
Practice Address - Phone:727-586-0545
Practice Address - Fax:727-586-0547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56269261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF06351Medicare UPIN