Healthcare Provider Details

I. General information

NPI: 1780052811
Provider Name (Legal Business Name): DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2015
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7691 5 MILE RD SUITE 312
CINCINNATI OH
45230-4348
US

IV. Provider business mailing address

5300 FAR HILLS AVE
DAYTON OH
45429-2381
US

V. Phone/Fax

Practice location:
  • Phone: 513-232-3332
  • Fax: 513-232-9635
Mailing address:
  • Phone: 937-433-7536
  • Fax: 937-433-9612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004150
License Number StateOH

VIII. Authorized Official

Name: JOHN C. LEPAGE
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 937-433-7536