Healthcare Provider Details

I. General information

NPI: 1780759415
Provider Name (Legal Business Name): DERMATOLOGY AND SKIN SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 A MARKET STREET
NEW ALBANY OH
43054
US

IV. Provider business mailing address

240 A MARKET STREET
NEW ALBANY OH
43054
US

V. Phone/Fax

Practice location:
  • Phone: 614-855-5702
  • Fax: 614-855-3227
Mailing address:
  • Phone: 614-855-5702
  • Fax: 614-855-3227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35047090
License Number StateOH

VIII. Authorized Official

Name: MR. LARRY JOHN LITTLE
Title or Position: OWNER
Credential: MD
Phone: 641-855-5702