Provider Demographics
NPI:1588791255
Name:ADVANCED DERMATOLOGY OF CHARLOTTESVILLE
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY OF CHARLOTTESVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANDANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:NANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-977-0027
Mailing Address - Street 1:66 PARKWAY LN
Mailing Address - Street 2:SUITE 101 C
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2384
Mailing Address - Country:US
Mailing Address - Phone:434-977-0027
Mailing Address - Fax:434-978-2040
Practice Address - Street 1:600 PETER JEFFERSON PKWY
Practice Address - Street 2:SUITE 350
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8835
Practice Address - Country:US
Practice Address - Phone:434-977-0027
Practice Address - Fax:434-978-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA06-00006615174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA221022OtherANTHEM
VA413137OtherSOUTHERN HEALTH
VAC09772Medicare ID - Type Unspecified