Provider Demographics
NPI:1770451007
Name:HISTODERM GROUP LLC
Entity type:Organization
Organization Name:HISTODERM GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISVETT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-934-5046
Mailing Address - Street 1:7091 SW 47TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4652
Mailing Address - Country:US
Mailing Address - Phone:305-934-5046
Mailing Address - Fax:
Practice Address - Street 1:7091 SW 47TH ST STE C
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4652
Practice Address - Country:US
Practice Address - Phone:305-934-5046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-28
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory ManagementGroup - Multi-Specialty