Healthcare Provider Details

I. General information

NPI: 1417450883
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF MASS AVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 MASSACHUSETTS AVE NW STE 308
WASHINGTON DC
20016-4382
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 202-695-1000
  • Fax: 202-503-1791
Mailing address:
  • Phone: 561-314-2000
  • Fax: 561-431-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAM S. PLOTKIN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 561-314-2000