Provider Demographics
NPI:1780659094
Name:CLEARWATER DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:CLEARWATER DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:GOLOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-461-2282
Mailing Address - Street 1:1122 DRUID RD E
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-4100
Mailing Address - Country:US
Mailing Address - Phone:727-461-2282
Mailing Address - Fax:
Practice Address - Street 1:1122 DRUID RD E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-4100
Practice Address - Country:US
Practice Address - Phone:727-461-2282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0021279207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0004563725OtherAETNA PROV CLWR DERM
FL0300627OtherUHC GROUP # CLWR DERM
FL250114700Medicaid
FLCI8446Medicare PIN
FL250114700Medicaid