Healthcare Provider Details

I. General information

NPI: 1790177210
Provider Name (Legal Business Name): SHADY GROVE DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 03/05/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15245 SHADY GROVE RD SUITE 370
ROCKVILLE MD
20850-3222
US

IV. Provider business mailing address

15245 SHADY GROVE RD SUITE 370
ROCKVILLE MD
20850-3222
US

V. Phone/Fax

Practice location:
  • Phone: 240-246-7417
  • Fax:
Mailing address:
  • Phone: 240-246-7417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0028453
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SANDEE HALL DAVIDSON
Title or Position: BUSINESS CONSULTANT
Credential:
Phone: 240-246-7417