Basic Information
| Provider Information | |||||||||
| NPI: | 1629396841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED DERMATOLOGY OF BOUNTIFUL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 EXCHANGE CT STE 110 | ||||||||
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| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334314450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1222 W LEGACY CROSSING BLVD STE 200 | ||||||||
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| City: | CENTERVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840145560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012983802 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | PLOTKIN | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5613142000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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.