Provider Demographics
NPI:1720799232
Name:PROMENADES DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:PROMENADES DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAROUDI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:941-627-5155
Mailing Address - Street 1:3222 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8048
Mailing Address - Country:US
Mailing Address - Phone:941-627-5155
Mailing Address - Fax:
Practice Address - Street 1:3222 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8048
Practice Address - Country:US
Practice Address - Phone:941-627-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty