Unknown Individual – Dermatology Physician, NPI 1063670412

Unknown Individual is a healthcare provider. based in Maitland, Florida. specializing in Dermatology Physician. They hold a License No. ME115923 (FL). The NPI Number for Unknown Individual is 1063670412

Main info

Organization
Inactive
51 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1063670412
Phone
(407) 875-2080
Address
151 SOUTHHALL LN
Deactivation Date
4 September 2024

Doctor Profile

Medical School Name
WAKE FOREST UNIVERSITY SCHOOL OF MEDICINE
Secondary Phone
3526202420
Graduation Year
1975 (51 years ago)
PAC ID
3870546484
Group Practice PAC ID
4688579311
Professional Enrollment ID
I20130613000526
Data current as of
20 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience23
Completeness75
Years active:0State licenses:2Digital endpointsOther names

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Provider Addresses for Unknown Individual

  • 151 Southpoint, 151, Southhall Lane, Maitland, Orange County, Florida, 32810, United States

    SUITE 300

    MAITLAND, FL 327517176

    Phone: (407) 875-2080

    Fax: (407) 650-3455

    Type: Mailing

  • Southeast 17th Street, Ocala, Marion County, Florida, 34471:34474, United States

    OCALA, FL 344714120

    Phone: (352) 620-2420

    Fax: (352) 620-2935

    Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 32751)

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Provider's Procedures

Unknown Individual performs procedures in Dermatology Physician. See the list of HCPCS codes below.
SpecialtyPractice State
HCPCS Code
Description
Service Count
Beneficiary Count
DERMATOLOGYFL11101Biopsy of each additional growth of skin and/or tissue6745
DERMATOLOGYFL17003Destruction of 2-14 skin growths1505242

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 4688579311View full group profile
NameSpecialtyState
JAMES SOLOMON (MD)
-NV
DR. LISA NYANDA-MANALO (MD)
D E R M A T O L O G YFL
LUCIA KRAUS (PA)
-FL
DANIELLE ELIZABETH MARINO
Nurse PractitionerFL
MATTHEW M HENDRICKS (PA-C)
-FL
SCOTT PODNOS (MD)
Dermatology, Micrographic Dermatologic Surgery (Mds)FL
RAYMOND RAMIREZ (DO)
D E R M A T O L O G YFL
REBECCA LEYNES (PA-C)
Physician AssistantFL
NICKY GAZY
D E R M A T O L O G YMI
STEPHEN A SPENCER (MD PA)
Dermatology, Micrographic Dermatologic Surgery (Mds)FL

Reviews

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Frequently asked questions

Can I use this page to confirm Unknown Individual's NPI?
Yes. Unknown Individual is listed with NPI 1063670412 in the public NPI dataset.
Is Unknown Individual's NPI deactivated?
The extract indicates Unknown Individual is not in an active NPI state.
What is Unknown Individual's primary classification?
Dermatology Physician is the headline specialty for Unknown Individual here. Clinical services aligned with this taxonomy classification.
What area does Unknown Individual serve?
Unknown Individual's listing highlights Maitland, Florida; more addresses can appear in NPPES.
Why does Unknown Individual have multiple addresses?
2 practice locations appear in the available data. Multiple addresses are common for hospital privileges, telehealth, or multi-site groups.

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