Provider Demographics
NPI:1871375055
Name:INTRACOASTAL DERMATOLOGY AND SKIN SURGERY PLLC
Entity type:Organization
Organization Name:INTRACOASTAL DERMATOLOGY AND SKIN SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:910-631-0301
Mailing Address - Street 1:509 OLDE WATERFORD WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 OLDE WATERFORD WAY STE 103
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4126
Practice Address - Country:US
Practice Address - Phone:910-631-0301
Practice Address - Fax:910-292-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty