Provider Demographics
NPI:1174078281
Name:DERMATOLOGY AND SKIN CANCER SURGERY CENTER, LLC
Entity type:Organization
Organization Name:DERMATOLOGY AND SKIN CANCER SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VITALY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLATNOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-706-1770
Mailing Address - Street 1:7560 RED BUG LAKE RD STE 1014
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6591
Mailing Address - Country:US
Mailing Address - Phone:407-706-1770
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:7560 RED BUG LAKE RD STE 1014
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6591
Practice Address - Country:US
Practice Address - Phone:407-706-1770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001633600Medicaid