Provider Demographics
NPI:1336899061
Name:DERMATOLOGIST LLC
Entity type:Organization
Organization Name:DERMATOLOGIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMIDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:216-280-1343
Mailing Address - Street 1:37045 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MORELAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-1238
Mailing Address - Country:US
Mailing Address - Phone:216-280-1343
Mailing Address - Fax:216-758-4783
Practice Address - Street 1:13638 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9638
Practice Address - Country:US
Practice Address - Phone:440-804-5996
Practice Address - Fax:216-758-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty