MR. EDWARD B LACK (NPI# 1417955584) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1417955584 |
| Entity Type | Individual |
| Full Name | MR. EDWARD B LACK |
| Credential | MD |
| Practice Address |
540 Medical Oaks Ave Suite 102 Brandon FL 33511-5995 |
| Mailing Address |
151 Southhall Ln Suite 300 Maitland FL 32751-7176 |
| Practice Telephone | 8136511991 |
| Practice Fax Number | 8136511401 |
| Mailing Telephone | 4078752080 |
| Mailing Fax Number | 4076503544 |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2016-11-15 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 207N00000X | Dermatology | ME114654 | FL | Allopathic & Osteopathic Physicians |
| Y | 207N00000X | Dermatology | 036-043409 | IL | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| BCBS | 0021603804 | 01 |
| Street Address |
540 MEDICAL OAKS AVE SUITE 102 |
| City | BRANDON |
| State | FL |
| Zip Code | 33511-5995 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1699771873 | Lawrence Carol Taylor Jr. | Ophthalmology | 540 Medical Oaks Ave, Suite 103, Brandon, FL 33511-5995 | 2005-06-22 |
| 1538327036 | Leavitt Medical Associates of Florida Inc | Dermatology | 540 Medical Oaks Ave, Suite 102, Brandon, FL 33511-5961 | 2008-05-30 |
| 1215969357 | Brandon Eye Associates Pa | Optometrist | 540 Medical Oaks Ave, Suite 103, Brandon, FL 33511-5995 | 2006-07-07 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1295367555 | Ability Beyond Measures LLC. | Clinic/Center | 2705 Isabella Valley Court, Brandon, FL 33511 | 2020-02-05 |
| 1831744655 | Brandon Modern Dentistry, Pa | Dentist | 971 E. Bloomingdale Avenue, Brandon, FL 33511 | 2019-08-08 |
| 1487208922 | Heart and Vascular Center of Brandon, Pllc | Internal Medicine | 511 Medical Oaks Ave., Brandon, FL 33511 | 2019-08-01 |
| 1841842895 | Rebecca Harrelson | Counselor | 915 Oakfield Drive, Suite E, Brandon, FL 33511 | 2019-07-10 |
| 1043779713 | Cheryl Diane Hart | Nurse Practitioner | 888 S Parsons Ave., Brandon, FL 33511 | 2019-03-13 |
| 1306303177 | Paula J Buchwald | Nurse Practitioner | 888 S. Parsons Ave, Brandon, FL 33511 | 2019-02-27 |
| 1063993996 | Ashlee Marie Shevchenko | Speech-Language Pathologist | 602 Vondeburg Dr, Suite 201, Brandon, FL 33511 | 2018-08-28 |
| 1275023012 | Ava Cares, LLC | Assisted Living Facility | 3005 Bell Shoals Rd., Brandon, FL 33511 | 2018-05-17 |
| 1346738705 | Tampa Psychology Group | Psychologist | 1463 Oakfield Dr Ste 109, Brandon, FL 33511 | 2018-05-01 |
| 1760982987 | Suresh Lama Tamang | Counselor | 510 Vonderburg Dr, Suite# 301, Brandon, FL 33511 | 2018-02-14 |
| Find all providers in zip 33511 | ||||
| Taxonomy Code | 207N00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Dermatology |
| A dermatologist is trained to diagnose and treat pediatric and adult patients with benign and malignant disorders of the skin, mouth, external genitalia, hair and nails, as well as a number of sexually transmitted diseases. The dermatologist has had additional training and experience in the diagnosis and treatment of skin cancers, melanomas, moles and other tumors of the skin, the management of contact dermatitis and other allergic and nonallergic skin disorders, and in the recognition of the skin manifestations of systemic (including internal malignancy) and infectious diseases. Dermatologists have special training in dermatopathology and in the surgical techniques used in dermatology. They also have expertise in the management of cosmetic disorders of the skin such as hair loss and scars and the skin changes associated with aging. |
| Notes: Source: American Board of Medical Specialties, 2007. www.abms.org [7/1/2007: added definition, added source] Additional Resources: American Board of Dermatology, 2007. http://www.abderm.org/ Board certification is provided by the American Board of Dermatology. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1760504682 | Brandon Dermatology P A | Dermatology | 405 W Bloomingdale Ave, Brandon, FL 33511-7401 | 2007-04-03 |
| 1780799460 | Andres Tobon | Dermatology | 405 W. Bloomingdale Ave, Brandon, FL 33511-7401 | 2006-08-20 |
| 1891728861 | Bay Dermatology Associates Jerry L Hedrick Md Pa | Dermatology | 500 Vonderburg Drive, Ste 115w, Brandon, FL 33511-5969 | 2006-07-10 |
| 1174586481 | Nancy S Ling | Dermatology | 305 Bryan Rd, Suite 5 & 6, Brandon, FL 33511-5340 | 2006-04-08 |
| 1578556387 | Susan Lynn Malane | Dermatology | 116 S Montclair Ave, Brandon, FL 33511-5322 | 2005-08-26 |
| 1194103812 | Brandon Comprehensive Dermatology Pa | Dermatology | 116 S Montclair Ave, Brandon, FL 33511-5322 | 2015-05-14 |
| 1417396714 | Brittany Erin Hearn | Dermatology | 621 Medical Care Dr, Brandon, FL 33511-5942 | 2013-06-19 |
| 1639446305 | Prakit Jeerapaet Md Pa | Dermatology | 116 S Montclair Ave, Brandon, FL 33511-5322 | 2011-11-24 |
| 1659698371 | Nancy Simons Ling Md Pa | Dermatology | 305 Bryan Rd, Suite 5 & 6, Brandon, FL 33511-5340 | 2010-04-21 |
| 1730348673 | Ricardo Luis Berrios | Dermatology | 405 W Bloomingdale Ave, Brandon, FL 33511-7401 | 2008-06-05 |
| Find all providers in BRANDON | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.