Provider Demographics
NPI:1154616647
Name:WEATHERALL DERMATOLOGY, P.A.,
Entity type:Organization
Organization Name:WEATHERALL DERMATOLOGY, P.A.,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:GIANCOLA
Authorized Official - Last Name:WEATHERALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-459-5050
Mailing Address - Street 1:6877 SW 18TH ST
Mailing Address - Street 2:SUITE H201
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-7046
Mailing Address - Country:US
Mailing Address - Phone:561-459-5050
Mailing Address - Fax:561-347-1455
Practice Address - Street 1:6877 SW 18TH ST
Practice Address - Street 2:SUITE H201
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-7046
Practice Address - Country:US
Practice Address - Phone:561-459-5050
Practice Address - Fax:561-347-1455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFD311AMedicare PIN