Healthcare Provider Details

I. General information

NPI: 1598785016
Provider Name (Legal Business Name): PARK DERMATOLOGY ASSOC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE PEARL ST STE 2300
BROCKTON MA
02301
US

IV. Provider business mailing address

ONE PEARL ST STE 2300
BROCKTON MA
02301
US

V. Phone/Fax

Practice location:
  • Phone: 508-894-5100
  • Fax: 508-894-5111
Mailing address:
  • Phone: 508-894-5100
  • Fax: 508-894-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY M RITT
Title or Position: PHYSICIAN
Credential: MD
Phone: 508-894-5100