Provider Demographics
NPI:1912390212
Name:BRANDON COMPREHENSIVE DERMATOLOGY
Entity Type:Organization
Organization Name:BRANDON COMPREHENSIVE DERMATOLOGY
Other - Org Name:BRANDON COMPREHENSIVE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALANE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-846-7507
Mailing Address - Street 1:116 S MONTCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5322
Mailing Address - Country:US
Mailing Address - Phone:813-685-7714
Mailing Address - Fax:
Practice Address - Street 1:116 S MONTCLAIR AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5322
Practice Address - Country:US
Practice Address - Phone:813-685-7714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7746261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center