Provider Demographics
NPI:1992938906
Name:DERMATOLOGY ASSOCIATES OF SOUTHWEST WASHINGTON, PLLC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF SOUTHWEST WASHINGTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:DATLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-254-5267
Mailing Address - Street 1:8614 E MILL PLAIN BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2059
Mailing Address - Country:US
Mailing Address - Phone:360-254-5267
Mailing Address - Fax:360-254-6089
Practice Address - Street 1:8614 E MILL PLAIN BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2059
Practice Address - Country:US
Practice Address - Phone:360-254-5267
Practice Address - Fax:360-254-6089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7065758Medicaid
WA7065758Medicaid