Organization
INTEGRATED DERMATOLOGY OF PONCHATOULA, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY QUEEN (MANAGER)
(561) 314-2000
Entity
Organization
Contact information
Practice address
180 N 5TH ST, PONCHATOULA, LA 70454-2532
(985) 370-7546
Mailing address
4700 EXCHANGE CT STE 110, BOCA RATON, FL 33431-4450
(561) 314-2000
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
Other
Enumeration date
09/04/2015
Last updated
05/21/2019
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