Provider Demographics
NPI:1205270824
Name:SKIN DERMATOLOGY AND COSMETIC SERVICES, P.A.
Entity type:Organization
Organization Name:SKIN DERMATOLOGY AND COSMETIC SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-599-7546
Mailing Address - Street 1:865 SAXON BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8204
Mailing Address - Country:US
Mailing Address - Phone:386-256-1969
Mailing Address - Fax:407-599-7506
Practice Address - Street 1:865 SAXON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8204
Practice Address - Country:US
Practice Address - Phone:386-256-1969
Practice Address - Fax:407-599-7506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73845174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2608936Medicaid