Healthcare Provider Details

I. General information

NPI: 1225855307
Provider Name (Legal Business Name): EQUITY DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 ROCKINGHAM AVE
BOWLING GREEN KY
42104-3348
US

IV. Provider business mailing address

1802 ROCKINGHAM AVE
BOWLING GREEN KY
42104-3348
US

V. Phone/Fax

Practice location:
  • Phone: 270-213-7777
  • Fax: 844-444-1250
Mailing address:
  • Phone: 270-213-7777
  • Fax: 844-444-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JAMES T ALLRED
Title or Position: DOCTOR/OWNER
Credential: MD
Phone: 615-428-4063