Healthcare Provider Details

I. General information

NPI: 1548213606
Provider Name (Legal Business Name): MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 MONTVALE AVE STE 3000
STONEHAM MA
02180-3658
US

IV. Provider business mailing address

526 MAIN ST STE 302
ACTON MA
01720-3301
US

V. Phone/Fax

Practice location:
  • Phone: 781-438-6350
  • Fax: 781-279-0430
Mailing address:
  • Phone: 978-371-7010
  • Fax: 978-371-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL D GOOS
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 978-371-7010