Provider Demographics
NPI:1669251112
Name:ORLANDO DERMATOLOGY CLINIC LLC
Entity type:Organization
Organization Name:ORLANDO DERMATOLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-218-3211
Mailing Address - Street 1:1040 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 W ORANGE ST
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2537
Practice Address - Country:US
Practice Address - Phone:352-218-3211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty