Healthcare Provider Details

I. General information

NPI: 1871576165
Provider Name (Legal Business Name): SKIN DIAGNOSTIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 MONTGOMERY RD
CINCINNATI OH
45242-7750
US

IV. Provider business mailing address

PO BOX 643290
CINCINNATI OH
45264-3290
US

V. Phone/Fax

Practice location:
  • Phone: 513-631-0059
  • Fax: 513-631-0068
Mailing address:
  • Phone: 513-631-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BEATRIZ PORRAS
Title or Position: PRESIDENT
Credential: MD
Phone: 513-631-0059