Provider Demographics
NPI:1679354393
Name:DERMATOLOGY AND MOHS SURGERY CENTER LLC
Entity type:Organization
Organization Name:DERMATOLOGY AND MOHS SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-336-0033
Mailing Address - Street 1:110 BUSINESS PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7449
Mailing Address - Country:US
Mailing Address - Phone:417-336-0033
Mailing Address - Fax:855-710-6552
Practice Address - Street 1:12139 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32407-2609
Practice Address - Country:US
Practice Address - Phone:417-336-0033
Practice Address - Fax:855-710-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty