Provider Demographics
NPI:1154735819
Name:ELITE DERMATOLOGY AND AESTHETIC INSTITUTE, LLC
Entity type:Organization
Organization Name:ELITE DERMATOLOGY AND AESTHETIC INSTITUTE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINKELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-826-6650
Mailing Address - Street 1:1905 CLINT MOORE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2658
Mailing Address - Country:US
Mailing Address - Phone:561-826-6650
Mailing Address - Fax:561-826-6649
Practice Address - Street 1:1905 CLINT MOORE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2658
Practice Address - Country:US
Practice Address - Phone:561-826-6650
Practice Address - Fax:561-826-6649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS1629207Q00000X
FLOS10617207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11877AOtherMEDICARE PTAN