Healthcare Provider Details

I. General information

NPI: 1104094655
Provider Name (Legal Business Name): EASTON DERMATOLOGY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MARVEL CT
EASTON MD
21601-4053
US

IV. Provider business mailing address

403 MARVEL CT
EASTON MD
21601-4053
US

V. Phone/Fax

Practice location:
  • Phone: 410-819-8867
  • Fax: 410-822-0416
Mailing address:
  • Phone: 410-819-8867
  • Fax: 410-822-0416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0059921
License Number StateMD

VIII. Authorized Official

Name: MR. MICHAEL A DEL TORTO
Title or Position: OWNER
Credential: M.D.
Phone: 410-819-8867