NPIMap

Organization Active NPI

Shadetree Dermatology LLC

  • Dermatology Physician
  • Cocoa Beach, FL
National Provider Identifier
1366297376
Registry record updated Mar 4, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
SHADETREE DERMATOLOGY LLC
Practice address
105 S Banana River Blvd FL 2
Cocoa Beach, FL 32931-5041
Phone
(321) 200-0346
NPI assigned
Apr 22, 2024
Last updated
Mar 4, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2026

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

Authorized official

Name
Dr. Vanessa Emily Johnson, MDNPI 1972948875
Title
Dermatologist (Physician)
Phone
(321) 200-0346

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 Physician 207N00000X Primary

Addresses

Primary practice location

105 S Banana River Blvd FL 2
Cocoa Beach, FL 32931-5041

Mailing address

105 S Banana River Blvd FL 2
Cocoa Beach, FL 32931-5041
Phone (321) 200-0346

Other practice location 1

389 Commerce Pkwy Ste 160
Rockledge, FL 32955-4202
Phone (321) 200-0346

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240624005062 FL Part B Supplier - Clinic/Group Practice 8628511227 Receives reassigned benefits from 6 practitioners
Practice locations: Cocoa Beach, FL

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1713744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1772582400000",
    "number": "1366297376",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "105 S BANANA RIVER BLVD FL 2",
            "city": "COCOA BEACH",
            "state": "FL",
            "postal_code": "329315041",
            "telephone_number": "321-200-0346"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 S BANANA RIVER BLVD FL 2",
            "city": "COCOA BEACH",
            "state": "FL",
            "postal_code": "329315041",
            "telephone_number": "321-200-0346"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "389 Commerce Pkwy Ste 160",
            "address_purpose": "LOCATION",
            "city": "Rockledge",
            "state": "FL",
            "postal_code": "329554202",
            "country_code": "US",
            "telephone_number": "321-200-0346",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "SHADETREE DERMATOLOGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-04-22",
        "last_updated": "2026-03-04",
        "certification_date": "2026-03-04",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "VANESSA",
        "authorized_official_middle_name": "EMILY",
        "authorized_official_title_or_position": "DERMATOLOGIST (PHYSICIAN)",
        "authorized_official_telephone_number": "321-200-0346",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cocoa Beach, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.