Healthcare Provider Details

I. General information

NPI: 1538415369
Provider Name (Legal Business Name): SKIN DOCS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 BLACK ROCK TPKE HALL 2
FAIRFIELD CT
06825-3220
US

IV. Provider business mailing address

2321 BLACK ROCK TPKE HALL 2
FAIRFIELD CT
06825-3220
US

V. Phone/Fax

Practice location:
  • Phone: 404-805-2290
  • Fax: 203-372-0506
Mailing address:
  • Phone: 404-805-2290
  • Fax: 203-372-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: LOUIS MAZZELLA
Title or Position: SOLE MEMBER
Credential: MD
Phone: 404-805-2290