Healthcare Provider Details

I. General information

NPI: 1730567504
Provider Name (Legal Business Name): DERMATOLOGY ASSOCIATES OF TALLAHASSEE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4233 CAMELOT XING
VALDOSTA GA
31602-6926
US

IV. Provider business mailing address

PO BOX 13834
TALLAHASSEE FL
32317-3834
US

V. Phone/Fax

Practice location:
  • Phone: 229-469-4383
  • Fax: 229-469-4584
Mailing address:
  • Phone: 850-205-6232
  • Fax: 850-402-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN RICHARDSON
Title or Position: BOARD SECRETARY
Credential: MD
Phone: 850-877-4134