Healthcare Provider Details

I. General information

NPI: 1801819883
Provider Name (Legal Business Name): DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 FAR HILLS AVE
DAYTON OH
45429-2347
US

IV. Provider business mailing address

5300 FAR HILLS AVE
DAYTON OH
45429-2347
US

V. Phone/Fax

Practice location:
  • Phone: 937-433-7536
  • Fax: 937-433-9612
Mailing address:
  • Phone: 937-433-7536
  • Fax: 937-433-9612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number1801819883
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1801819883
License Number StateOH

VIII. Authorized Official

Name: JOHN MACKE
Title or Position: C.E.O.
Credential:
Phone: 937-433-7536