Provider Demographics
NPI:1104094655
Name:EASTON DERMATOLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:EASTON DERMATOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEL TORTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-819-8867
Mailing Address - Street 1:403 MARVEL CT
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-4053
Mailing Address - Country:US
Mailing Address - Phone:410-819-8867
Mailing Address - Fax:410-822-0416
Practice Address - Street 1:403 MARVEL CT
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4053
Practice Address - Country:US
Practice Address - Phone:410-819-8867
Practice Address - Fax:410-822-0416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059921174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH91347Medicare UPIN