1487186466 NPI number — INTEGRATED DERMATOLOGY OF RESTON, LLC

Table of content: (NPI 1487186466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487186466 NPI number — INTEGRATED DERMATOLOGY OF RESTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
INTEGRATED DERMATOLOGY OF RESTON, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1487186466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 EXCHANGE CT STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-4450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-314-2000
Provider Business Mailing Address Fax Number:
561-431-2821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1886 METRO CENTER DR STE 650
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20190-5294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-437-7744
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PLOTKIN
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
561-314-2000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)