Provider Demographics
NPI:1831187764
Name:OPTIMA DERMATOLOGY LLC
Entity type:Organization
Organization Name:OPTIMA DERMATOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-965-8760
Mailing Address - Street 1:111 NEW HAMPSHIRE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2864
Mailing Address - Country:US
Mailing Address - Phone:802-909-2053
Mailing Address - Fax:330-965-9325
Practice Address - Street 1:987 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4222
Practice Address - Country:US
Practice Address - Phone:330-965-8760
Practice Address - Fax:330-965-9325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========001OtherTRICARE SALEM GROUP
OH=========OtherTRICARE BOARDMAN GROUP
OH9315041Medicare PIN
OH9315042Medicare PIN