Provider Demographics
NPI:1487613907
Name:ADULT AND PEDIATRIC DERMATOLOGY PRACTITIONERS P A
Entity type:Organization
Organization Name:ADULT AND PEDIATRIC DERMATOLOGY PRACTITIONERS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MASESSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-625-0600
Mailing Address - Street 1:35 GREEN POND RD STE C
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-2057
Mailing Address - Country:US
Mailing Address - Phone:973-625-0600
Mailing Address - Fax:973-625-2909
Practice Address - Street 1:715 W BOYNTON BEACH BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-3625
Practice Address - Country:US
Practice Address - Phone:561-364-2626
Practice Address - Fax:561-364-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA851OtherMEDICARE