NPIMap

Organization Active NPI

Orlando Dermatology Clinic, LLC

  • Dermatology Physician
  • Orange City, FL
National Provider Identifier
1043900947
Registry record updated Nov 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
ORLANDO DERMATOLOGY CLINIC, LLC
Practice address
2548 S Volusia Ave
Orange City, FL 32763-9124
Phone
(352) 218-3211
NPI assigned
May 12, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 24, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tarek S ShaathNPI 1366823775
Title
Owner
Phone
(352) 218-3211

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

2548 S Volusia Ave
Orange City, FL 32763-9124

Mailing address

1040 Lake Sumter LNDG
The Villages, FL 32162-2697

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2323638Orlando Dermatology Clinic LLC2548 S Volusia Ave, Orange City, FL 32763RegistrationMay 8, 2027

National Provider Directory

National Provider Directory
Tax ID family
Orlando Dermatology Clinic LLC7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1683849600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700784000000",
    "number": "1043900947",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1040 LAKE SUMTER LNDG",
            "city": "THE VILLAGES",
            "state": "FL",
            "postal_code": "321622697"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2548 S VOLUSIA AVE",
            "city": "ORANGE CITY",
            "state": "FL",
            "postal_code": "327639124",
            "telephone_number": "352-218-3211"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ORLANDO DERMATOLOGY CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-05-12",
        "last_updated": "2023-11-24",
        "certification_date": "2023-11-24",
        "status": "A",
        "authorized_official_last_name": "SHAATH",
        "authorized_official_first_name": "TAREK",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "352-218-3211"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Orange City, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.