Provider Demographics
NPI:1295278943
Name:FLORIDA DERMATOLOGY PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:FLORIDA DERMATOLOGY PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALUJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-917-3067
Mailing Address - Street 1:PO BOX 628721
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32862-8721
Mailing Address - Country:US
Mailing Address - Phone:321-241-1160
Mailing Address - Fax:
Practice Address - Street 1:6559 N WICKHAM RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2039
Practice Address - Country:US
Practice Address - Phone:321-345-0552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118444208200000X
FLM82777207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty