1508996430 NPI number — MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.

Table of content: (NPI 1508996430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508996430 NPI number — MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508996430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 MONTVALE AVE
Provider Second Line Business Mailing Address:
3000
Provider Business Mailing Address City Name:
STONEHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02180-3647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-438-6350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
92 HIGH ST
Provider Second Line Business Practice Location Address:
T21
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-3850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-391-0778
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOOS
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
978-371-7010

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)





Copyright © 2007-2025 www.npivalidator.com