Provider Demographics
NPI:1841049541
Name:DOCTOR K DEREM LLC
Entity type:Organization
Organization Name:DOCTOR K DEREM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAUTILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAURYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-271-6522
Mailing Address - Street 1:2100 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8110
Mailing Address - Country:US
Mailing Address - Phone:321-752-7100
Mailing Address - Fax:321-752-7105
Practice Address - Street 1:2100 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8110
Practice Address - Country:US
Practice Address - Phone:321-752-7100
Practice Address - Fax:321-752-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty