Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 208D00000X | General Practice | | ME125579 | FLORIDA | No |
| 2 | 207N00000X | Dermatology | | ME127579 | FLORIDA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 25MA11191500 | OTHER | NEW JERSEY | NEW JERSEY |
| 2 | 33739 | OTHER | NEBRASKA | NEBRASKA MEDICAL LICENSE |
| 3 | 42609 | OTHER | ALABAMA | ALABAMA MEDICAL LICENSE |
| 4 | 76339 | OTHER | WISCONSIN | WISCONSIN MEDICAL LICENSE |
| 5 | D0092430 | OTHER | MARYLAND | MARYLAND MEDICAL LICENSE |
| 6 | MD24935 | OTHER | MAINE | MAINE MEDICAL LICENSE |
| 7 | MED-PHYS-LIC-99482 | OTHER | MONTANA | MONTANA MEDICAL LICENSE |
| 8 | 36157146 | OTHER | ILLINOIS | ILLINOIS MEDICAL LICENSE |
| 9 | 89503 | OTHER | GEORGIA | GEORGIA MEDICAL LICENSE |
| 10 | M-15901 | OTHER | IDAHO | IDAHO MEDICAL LICENSE |
| 11 | MD.MD.61175718 | OTHER | WASHINGTON | WASHINGTON MEDICAL LICENSE |
| 12 | 12839 | OTHER | SOUTH DAKOTA | SOUTH DAKOTA MEDICAL LICENSE |
| 13 | 21332 | OTHER | NEVADA | NEVADA MEDICAL LICENSE |
| 14 | 310885 | OTHER | NEW YORK | NEW YORK MEDICAL LICENSE |
| 15 | 328228 | OTHER | LOUISIANA | LOUISIANA MEDICAL LICENSE |
| 16 | 38429 | OTHER | OKLAHOMA | OKLAHOMA MEDICAL LICENSE |
| 17 | 4301505093 | OTHER | MICHIGAN | MICHIGAN MEDICAL LICENSE |
| 18 | 69112 | OTHER | CONNECTICUT | CONNECTICUT MEDICAL LICENSE |
| 19 | DR.0066706 | OTHER | COLORADO | COLORADO MEDICAL LICENSE |
| 20 | T2572 | OTHER | TEXAS | TEXAS MEDICAL LICENSE |
| 21 | 176790 | OTHER | ALASKA | ALASKA MEDICAL LICENSE |
| 22 | 2021-02468 | OTHER | NORTH CAROLINA | NORTH CAROLINA MEDICAL LICENSE |
| 23 | 290109 | OTHER | MASSACHUSETTS | MASSACHUSETTS MEDICAL LICENSE |
| 24 | 35.142712 | OTHER | OHIO | OHIO MEDICAL LICENSE |
| 25 | 55847 | OTHER | KENTUCKY | KENTUCKY MEDICAL LICENSE |
| 26 | 63956 | OTHER | TENNESSEE | TENNESSEE MEDICAL LICENSE |
| 27 | 72632 | OTHER | MINNESOTA | MINNESOTA MEDICAL LICENSE |
| 28 | A144337 | OTHER | CALIFORNIA | CALIFORNIA MEDICAL LICENSE |
| 29 | E-14484 | OTHER | ARKANSAS | ARKANSAS MEDICAL LICENSE |
| 30 | MD2021-0636 | OTHER | NEW MEXICO | NEW MEXICO |
| 31 | MD210001353 | OTHER | DISTRICT OF COLUMBIA | DC MEDICAL LICENSE |
| 32 | 01085912A | OTHER | INDIANA | INDIANA MEDICAL LICENSE |
| 33 | 13793A | OTHER | WYOMING | WYOMING MEDICAL LICENSE |
| 34 | 444908 | OTHER | KANSAS | KANSAS MEDICAL LICENSE |
| 35 | C1-0024474 | OTHER | DELAWARE | DELAWARE MEDICAL LICENSE |
| 36 | MD205616 | OTHER | OREGON | OREGON MEDICAL LICENSE |
| 37 | MD-22037 | OTHER | HAWAII | HAWAII MEDICAL LICENSE |
| 38 | MD17872 | OTHER | RHODE ISLAND | RHODE ISLAND MEDICAL LICENSE |
| 39 | ME127579 | OTHER | FLORIDA | FLORIDA MEDICAL LICENSE |
| 40 | 12328678-1205 | OTHER | UTAH | UTAH MEDICAL LICENSE |
| 41 | 17630 | OTHER | NORTH DAKOTA | NORTH DAKOTA MEDICAL LICENSE |
| 42 | 2021033997 | OTHER | MISSOURI | MISSOURI MEDICAL LICENSE |
| 43 | MD-48908 | OTHER | IOWA | IOWA MEDICAL LICENSE |
| 44 | MD474919 | OTHER | PENNSYLVANIA | PENNSYLVANIA MEDICAL LICENSE |
| 45 | 0101272120 | OTHER | VIRGINIA | VIRGINIA MEDICAL LICENSE |
| 46 | 21645 | OTHER | NEW HAMPSHIRE | NEW HAMPSHIRE |
| 47 | 29169 | OTHER | MISSISSIPPI | MISSISSIPPI MEDICAL LICENSE |
| 48 | 30538 | OTHER | WEST VIRGINIA | WEST VIRGINIA MEDICAL LICENSE |
| 49 | 64111 | OTHER | ARIZONA | ARIZONA MEDICAL LICENSE |
| 50 | 86375 | OTHER | SOUTH CAROLINA | SOUTH CAROLINA MEDICAL LICENSE |
