Provider Demographics
NPI:1427221605
Name:ACUTE DERMATOLOGY CLINIC PA
Entity type:Organization
Organization Name:ACUTE DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAU
Authorized Official - Middle Name:PAULINA
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-482-7546
Mailing Address - Street 1:PO BOX 101295
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33910-1295
Mailing Address - Country:US
Mailing Address - Phone:239-482-7546
Mailing Address - Fax:
Practice Address - Street 1:9400 GLADIOLUS DR
Practice Address - Street 2:SUITE 320
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-6699
Practice Address - Country:US
Practice Address - Phone:239-482-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9425261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJ932OtherMEDICARE PTAN
FL274238100Medicaid
I33972Medicare UPIN