1992938906 NPI number — DERMATOLOGY ASSOCIATES OF SOUTHWEST WASHINGTON, PLLC

Table of content: (NPI 1992938906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992938906 NPI number — DERMATOLOGY ASSOCIATES OF SOUTHWEST WASHINGTON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES OF SOUTHWEST WASHINGTON, PLLC
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:
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NPI Number Information

NPI Number:
1992938906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8614 E MILL PLAIN BLVD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98664-2059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-254-5267
Provider Business Mailing Address Fax Number:
360-254-6089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8614 E MILL PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-2059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-254-5267
Provider Business Practice Location Address Fax Number:
360-254-6089
Provider Enumeration Date:
08/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DATLOFF
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-254-5267

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7065758 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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