Organization
ASSOCIATED DERMATOLOGIST PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN C LONG JR. MD (OWNER)
(386) 672-3111
Entity
Organization
Contact information
Practice address
155 N NOVA RD, ORMOND BEACH, FL 32174-5138
(386) 672-3111
Mailing address
155 N NOVA RD, ORMOND BEACH, FL 32174-5138
(386) 672-3111
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
ME68137
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
K0008
MEDICARE
—
01
—
N6001
MEDICARE
—
Enumeration date
09/11/2007
Last updated
09/25/2007
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