Healthcare Provider Details

I. General information

NPI: 1285674952
Provider Name (Legal Business Name): RALEIGH DERMATOLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRINGFIELD COMMONS DR SUITE 115
RALEIGH NC
27609-8533
US

IV. Provider business mailing address

800 SPRINGFIELD COMMONS DR SUITE 115
RALEIGH NC
27609-8533
US

V. Phone/Fax

Practice location:
  • Phone: 919-876-3656
  • Fax: 919-876-2351
Mailing address:
  • Phone: 919-876-3656
  • Fax: 919-876-2351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: FERNANDO R PUENTE
Title or Position: OWNER
Credential: MD
Phone: 919-876-3656