Healthcare Provider Details

I. General information

NPI: 1225397458
Provider Name (Legal Business Name): WYNN KAO DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10705 CHARTER DR STE 330
COLUMBIA MD
21044-2885
US

IV. Provider business mailing address

10705 CHARTER DR STE 330
COLUMBIA MD
21044-2885
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-1287
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD70980
License Number StateMD

VIII. Authorized Official

Name: DR. WYNN KAO
Title or Position: DIRECTOR
Credential: M.D.
Phone: 410-730-1287