Provider Demographics
NPI:1487049722
Name:INNOVATIVE DERMATOLOGY AND MOHS SURGERY LLC
Entity type:Organization
Organization Name:INNOVATIVE DERMATOLOGY AND MOHS SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:P
Authorized Official - Last Name:KONTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-368-8071
Mailing Address - Street 1:3507 LEE BLVD
Mailing Address - Street 2:STE 107
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-1318
Mailing Address - Country:US
Mailing Address - Phone:239-368-8071
Mailing Address - Fax:239-368-8074
Practice Address - Street 1:3507 LEE BLVD
Practice Address - Street 2:STE 107
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1318
Practice Address - Country:US
Practice Address - Phone:239-368-8071
Practice Address - Fax:239-368-8074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96589207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty