Provider Demographics
NPI:1780894428
Name:DERMATOLOGY AND LASER CENTER PA
Entity type:Organization
Organization Name:DERMATOLOGY AND LASER CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-222-8323
Mailing Address - Street 1:PO BOX 18751
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07191-8751
Mailing Address - Country:US
Mailing Address - Phone:732-222-8323
Mailing Address - Fax:732-870-9488
Practice Address - Street 1:279 THIRD AVENUE
Practice Address - Street 2:SUITE 603
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6205
Practice Address - Country:US
Practice Address - Phone:732-222-8323
Practice Address - Fax:732-870-9488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06221000207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0675790000OtherAMERIHEALTH
NJ062544Medicare PIN
NJF20132Medicare UPIN
NJ0675790000OtherAMERIHEALTH