Healthcare Provider Details

I. General information

NPI: 1508092149
Provider Name (Legal Business Name): GUNNING DERMATOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 WISCONSIN AVE
CHEVY CHASE MD
20815-4404
US

IV. Provider business mailing address

12903 INNISBROOK DR
BELTSVILLE MD
20705-5104
US

V. Phone/Fax

Practice location:
  • Phone: 301-986-1880
  • Fax:
Mailing address:
  • Phone: 301-946-2369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberDOO62385
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD0062385
License Number StateMD

VIII. Authorized Official

Name: DR. SEAN THOMAS GUNNING
Title or Position: PRESIDENT
Credential: MD
Phone: 240-498-7356