Provider Demographics
NPI:1699285874
Name:SIMPLY DERMATOLOGY PLLC
Entity type:Organization
Organization Name:SIMPLY DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KALEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPANTONIOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-377-7222
Mailing Address - Street 1:900 WALT WHITMAN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2215
Mailing Address - Country:US
Mailing Address - Phone:631-377-7222
Mailing Address - Fax:631-621-5021
Practice Address - Street 1:900 WALT WHITMAN RD STE 101
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2215
Practice Address - Country:US
Practice Address - Phone:631-377-7222
Practice Address - Fax:631-621-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253792207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty