NPIMap

Organization Active NPI

Orlando Dermatology Clinic LLC

  • Dermatology Physician
  • Kissimmee, FL
National Provider Identifier
1609467109
Registry record updated Nov 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
ORLANDO DERMATOLOGY CLINIC LLC
Practice address
2970 Loopdale LN
Kissimmee, FL 34741-7658
Phone
(352) 218-3211
NPI assigned
Jan 28, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 3, 2022

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
(785) 760-6740

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X Primary
MOHS-Micrographic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207ND0101X
Procedural Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207NS0135X

Addresses

Primary practice location

2970 Loopdale LN
Kissimmee, FL 34741-7658

Mailing address

1040 Lake Sumter LNDG
The Villages, FL 32162-2697

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": "1611792000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1667433600000",
    "number": "1609467109",
    "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": "2970 LOOPDALE LN",
            "city": "KISSIMMEE",
            "state": "FL",
            "postal_code": "347417658",
            "telephone_number": "352-218-3211"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ORLANDO DERMATOLOGY CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-01-28",
        "last_updated": "2022-11-03",
        "certification_date": "2022-11-03",
        "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": "785-760-6740"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kissimmee, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 3, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.