1679682561 NPI number — THE DERM CENTER OF NEWTON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679682561 NPI number — THE DERM CENTER OF NEWTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE DERM CENTER OF NEWTON
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:
6
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:
1679682561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 945934
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30394-5934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-788-0620
Provider Business Mailing Address Fax Number:
678-342-3327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4155 BAKER ST NE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30014-1405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-788-0620
Provider Business Practice Location Address Fax Number:
678-342-3327
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VETETO
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-788-0620

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  038900 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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