Healthcare Provider Details

I. General information

NPI: 1619070224
Provider Name (Legal Business Name): WEST OHIO DERMATOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W HIGH ST STE 300
LIMA OH
45801-2967
US

IV. Provider business mailing address

750 W HIGH ST STE 300
LIMA OH
45801-2967
US

V. Phone/Fax

Practice location:
  • Phone: 419-229-6781
  • Fax: 419-229-3490
Mailing address:
  • Phone: 419-229-6781
  • Fax: 419-229-3490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35040604
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number35040604
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number35040604
License Number StateOH

VIII. Authorized Official

Name: DR. MICHAEL R HEAPHY SR.
Title or Position: PRESIDENT
Credential: MD
Phone: 419-229-6781