Provider Demographics
NPI:1124689831
Name:DERMATOLOGY AND MOHS SURGERY ASSOCIATES LLC
Entity type:Organization
Organization Name:DERMATOLOGY AND MOHS SURGERY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST AND MOHS SURGEON
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:DAVILA - DE PEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-764-6611
Mailing Address - Street 1:PO BOX 191259
Mailing Address - Street 2:525 FD ROOSEVELT AVENUE SUITE 712
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919
Mailing Address - Country:US
Mailing Address - Phone:787-764-6611
Mailing Address - Fax:787-957-3110
Practice Address - Street 1:525 FD ROOSEVELT AVENUE SUITE 712
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-764-6611
Practice Address - Fax:787-957-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR27404OtherMEDICAL CARD SYSTEM