Provider Demographics
NPI:1861687071
Name:ASSOCIATED DERMATOLOGIST PA
Entity Type:Organization
Organization Name:ASSOCIATED DERMATOLOGIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:386-672-3111
Mailing Address - Street 1:155 N NOVA RD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5138
Mailing Address - Country:US
Mailing Address - Phone:386-672-3111
Mailing Address - Fax:
Practice Address - Street 1:155 N NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5138
Practice Address - Country:US
Practice Address - Phone:386-672-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68137207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
N6001OtherMEDICARE
K0008OtherMEDICARE
FLG62265Medicare UPIN
K0008OtherMEDICARE