Provider Demographics
NPI:1780964460
Name:GALT DERMATOLOGY & CONCIERGE MEDICINE PA
Entity type:Organization
Organization Name:GALT DERMATOLOGY & CONCIERGE MEDICINE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLACORTA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-463-5406
Mailing Address - Street 1:800 E BROWARD BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2008
Mailing Address - Country:US
Mailing Address - Phone:954-463-5406
Mailing Address - Fax:
Practice Address - Street 1:800 E BROWARD BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2008
Practice Address - Country:US
Practice Address - Phone:954-463-5406
Practice Address - Fax:954-522-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36538174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1811442668OtherNPI
FL1811442668OtherNPI