Healthcare Provider Details

I. General information

NPI: 1689944811
Provider Name (Legal Business Name): NANTUCKET DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 10/28/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4.5 BARTLETT RD
NANTUCKET MA
02554
US

IV. Provider business mailing address

5 FEDERAL ST UNIT 1881
NANTUCKET MA
02554-1703
US

V. Phone/Fax

Practice location:
  • Phone: 781-398-2225
  • Fax: 781-398-2221
Mailing address:
  • Phone: 781-398-2225
  • Fax: 781-398-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number205049
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number205049
License Number StateMA

VIII. Authorized Official

Name: ABRAR A QURESHI
Title or Position: DIRECTOR
Credential: MD, MPH
Phone: 781-398-2225