Healthcare Provider Details

I. General information

NPI: 1750967691
Provider Name (Legal Business Name): MODERN DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W UNIVERSITY DR STE 314
ROCHESTER MI
48307-1876
US

IV. Provider business mailing address

1000 W UNIVERSITY DR STE 314
ROCHESTER MI
48307-1876
US

V. Phone/Fax

Practice location:
  • Phone: 248-375-4033
  • Fax: 248-375-4034
Mailing address:
  • Phone: 248-375-4033
  • Fax: 248-375-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIANA D ATANASOVSKI
Title or Position: DERMATOLOGIST
Credential: MD
Phone: 248-375-4033