Provider Demographics
NPI:1699892380
Name:TARA DERMATOLOGY CENTER PC
Entity type:Organization
Organization Name:TARA DERMATOLOGY CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:PENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-991-1000
Mailing Address - Street 1:191 MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5083
Mailing Address - Country:US
Mailing Address - Phone:770-991-1000
Mailing Address - Fax:
Practice Address - Street 1:191 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5083
Practice Address - Country:US
Practice Address - Phone:770-991-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2217Medicare PIN