Healthcare Provider Details

I. General information

NPI: 1104374081
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF CHEVY CHASE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 WISCONSIN AVE STE 1418
CHEVY CHASE MD
20815-4302
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 301-986-1880
  • Fax:
Mailing address:
  • Phone: 561-314-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAM S. PLOTKIN
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 561-314-2000