Basic Information
| Provider Information | |||||||||
| NPI: | 1588170591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED DERMATOLOGY OF GAINESVILLE, LLC | ||||||||
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| OtherOrganizationName: | FLORIDA SKIN CANCER AND DERMATOLOGY SPECIALIST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 EXCHANGE CT STE 110 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334314450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613142000 | ||||||||
| FaxNumber: | 5614312821 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 NW 83RD ST | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326065603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523717546 | ||||||||
| FaxNumber: | 3523357546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2017 | ||||||||
| LastUpdateDate: | 02/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | QUEEN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED GROUP OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5613142000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.