Provider Demographics
NPI:1104068790
Name:AESTHETIC DERMATOLOGY AND DERMATOLOGIC SURGERY CENTER
Entity type:Organization
Organization Name:AESTHETIC DERMATOLOGY AND DERMATOLOGIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:COATS-WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-809-4321
Mailing Address - Street 1:4321 COLLINGTON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-2259
Mailing Address - Country:US
Mailing Address - Phone:301-809-4321
Mailing Address - Fax:301-809-5798
Practice Address - Street 1:4321 COLLINGTON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-809-4321
Practice Address - Fax:301-809-5798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG87205Medicare UPIN