Healthcare Provider Details

I. General information

NPI: 1255316311
Provider Name (Legal Business Name): RITA OTILIA PICHARDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RITA OTILIA PICHARDO-GEISINGER MD

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4618 COUNTRY CLUB RD
WINSTON SALEM NC
27104-3520
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax: 336-716-9258
Mailing address:
  • Phone: 336-716-0238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number200500140
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number200500140
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number200500140
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number200500140
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: