Provider Demographics
NPI:1891257655
Name:ORLANDO DERMATOLOGY CLINIC, LLC
Entity Type:Organization
Organization Name:ORLANDO DERMATOLOGY CLINIC, LLC
Other - Org Name:CARE DERMATOLOGY AND SKIN CANCER CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DERMATOLOGIST, LLC PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:SAMIR
Authorized Official - Last Name:SHAATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:785-760-6740
Mailing Address - Street 1:697 OAK HOLLOW WAY
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-1838
Mailing Address - Country:US
Mailing Address - Phone:785-760-6740
Mailing Address - Fax:
Practice Address - Street 1:1040 LAKE SUMTER LNDG
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-2697
Practice Address - Country:US
Practice Address - Phone:352-218-3211
Practice Address - Fax:877-699-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-02
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty