Provider Demographics
NPI:1407663214
Name:DIVERGENT DERMATOLOGY AND AESTHETICS
Entity type:Organization
Organization Name:DIVERGENT DERMATOLOGY AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QAREN
Authorized Official - Middle Name:Q
Authorized Official - Last Name:QUARTEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-477-9883
Mailing Address - Street 1:18310 MONTGOMERY VILLAGE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18310 MONTGOMERY VILLAGE AVE STE 300
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3552
Practice Address - Country:US
Practice Address - Phone:240-813-8215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty