Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 036122668 | IL |
Y | 207N00000X | Dermatologist | ME106806 | FL |
N | 207ND0900X | Dermatopathologist | 036122668 | IL |
N | 207ND0900X | Dermatopathologist | ME106806 | FL |
NPI | 1043453970 |
---|---|
Provider Name | Dr. Justin Ross Wasserman |
First Address | Venice, FL 34285-4108 |
Second Address | Venice, FL 34285-4108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2009 |
Last Update Date | 16/12/2010 |