Healthcare Provider Details

I. General information

NPI: 1902385651
Provider Name (Legal Business Name): PRIMARY CARE DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8890 CENTRE PARK DR STE 300
COLUMBIA MD
21045-2198
US

IV. Provider business mailing address

PO BOX 45751
BALTIMORE MD
21297-5751
US

V. Phone/Fax

Practice location:
  • Phone: 410-696-7553
  • Fax:
Mailing address:
  • Phone:
  • 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: NATASHA SANDY
Title or Position: DOCTOR
Credential:
Phone: 410-696-7553