Organization
LUMINARY DERMATOLOGY, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JESSICA LYNN PHILLIPS (CEO)
(941) 302-4669
Entity
Organization
Contact information
Practice address
2101 61ST ST W, BRADENTON, FL 34209-5528
(941) 926-6553
Mailing address
4411 BEE RIDGE RD, PMB 309, SARASOTA, FL 34233-2514
(941) 926-6553
(941) 296-8501
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
—
—
207N00000X
Dermatology Physician
—
—
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
—
—
207VG0400X
Gynecology Physician
—
—
208200000X
Plastic Surgery Physician
—
—
208600000X
Surgery Physician
—
—
208D00000X
General Practice Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
363LA2200X
Adult Health Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
B8XVQ
FLORIDA BLUE
FL
Enumeration date
04/24/2019
Last updated
01/27/2025
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