Brandon Dermatology P a
Organization Active NPI Dermatology Physician · Brandon, FL
NPI 1760504682 · NPPES record last updated Sep 19, 2008
Key facts
- NPI
- 1760504682
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Dermatology Physician 207N00000X
- License
- OS7868 (FL)
- Legal business name
- BRANDON DERMATOLOGY P A
- Practice address
- 405 W Bloomingdale Ave
Brandon, FL 33511-7401 - Phone
- (813) 662-3376
- Fax
- (813) 662-3009
- NPI assigned
- Apr 3, 2007
- Organization subpart
- No
Authorized official
- Name
- Andres Tobon, D.O.
- Title
- Presidentphysician
- Phone
- (813) 662-3376
Practitioners 12
-
Andres Tobon, DO
-
Sanjay Agarwal, DO
-
Ricardo Luis Berrios, M.D.
-
Jennifer Nicole Harb, M.D.
-
Ritika Bhandari, M.D.
-
Pia Marie Cooper, PA-C
-
Rachel Lauren Smith, PA-C
-
Alison Kyle Treesh, PA-C
-
Shannon Rachelle Carie, PA-C
-
Lexy Hazle, PA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D2275813 | Brandon Dermatology, PA | Certificate of waiver | Jan 29, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080826000211 | FL | Part B Supplier - Clinic/Group Practice | 3779658786 |
Receives reassigned benefits from 12 practitioners Practice locations: Apollo Beach, FL; Brandon, FL; Plant City, FL; Tampa, FL |
National Provider Directory
Locations
6410 N US Highway 41
Apollo Beach, FL 33572
406 W Bloomingdale Ave
Brandon, FL 33511
Phone (813) 653-1880
405 W Bloomingdale Ave
Brandon, FL 33511
Phone (813) 662-3376
1501 S Alexander St
Ste 103
Plant City, FL 33563
Phone (813) 253-5969
4117 Henderson Blvd
Tampa, FL 33629
Phone (813) 207-8984
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/EICAAA
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician |
207N00000X | OS7868 | FL | Yes |
Addresses
Primary practice location
405 W Bloomingdale Ave
Brandon, FL 33511-7401
Mailing address
405 W Bloomingdale Ave
Brandon, FL 33511-7401
Phone (813) 662-3376
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| AL785 | Other | FL | MEDICARE PTAN |
Other providers in Brandon, FL
- Brandon Comprehensive Dermatology
- Brandon Comprehensive Dermatology PA
- Brandon Cosmetic and Family Dentistry
- Brandon Dental Care
- Brandon Dental Care PA
- Brandon Endodontics, PA
- Brandon Eye Associates PA
- Brandon Facility Operations LLC
- Brandon Family Dental Care LLC
- Brandon Family Medical Care PA
All providers in Brandon, FL · Dermatology Physician in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 19, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.