Provider Demographics
NPI:1013098755
Name:VILLAGE DERMATOLOGY & COSMETIC SURGERY, LLC
Entity Type:Organization
Organization Name:VILLAGE DERMATOLOGY & COSMETIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THI
Authorized Official - Middle Name:THIEN
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-751-6565
Mailing Address - Street 1:1950 LAUREL MANOR DR
Mailing Address - Street 2:BUILDING 220, SUITE 224
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5603
Mailing Address - Country:US
Mailing Address - Phone:352-751-6565
Mailing Address - Fax:352-205-7777
Practice Address - Street 1:1950 LAUREL MANOR DR
Practice Address - Street 2:BUILDING 220, SUITE 224
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162
Practice Address - Country:US
Practice Address - Phone:352-751-6565
Practice Address - Fax:352-205-7777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8364207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5937Medicare ID - Type Unspecified