Provider Demographics
NPI:1790395747
Name:DERMATOLOGY SPECIALISTS OF PENNSYLVANIA
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF PENNSYLVANIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONFENBRENER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-802-1310
Mailing Address - Street 1:1122 STREET RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-4218
Mailing Address - Country:US
Mailing Address - Phone:415-802-1310
Mailing Address - Fax:415-579-3505
Practice Address - Street 1:1122 STREET RD STE 204
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-4218
Practice Address - Country:US
Practice Address - Phone:415-802-1310
Practice Address - Fax:415-579-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty