Provider Demographics
NPI:1427128511
Name:DERMATOLGY & DERMATOLOGIC SURGERY PC
Entity type:Organization
Organization Name:DERMATOLGY & DERMATOLOGIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-928-9014
Mailing Address - Street 1:1021 W OAKLAND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2191
Mailing Address - Country:US
Mailing Address - Phone:423-928-9014
Mailing Address - Fax:423-928-3559
Practice Address - Street 1:1021 W OAKLAND DR
Practice Address - Street 2:SUITE 102
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-0000
Practice Address - Country:US
Practice Address - Phone:423-928-9014
Practice Address - Fax:423-928-3559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000013019207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0036521OtherBCBS
TN3701830Medicaid
TNTN0101OtherJOHN DEERE
TNTN0101OtherJOHN DEERE
TN3701830Medicare ID - Type Unspecified