Healthcare Provider Details

I. General information

NPI: 1487544292
Provider Name (Legal Business Name): DISCOVER DERMATOLOGY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2025
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CITY AVE STE 225
BALA CYNWYD PA
19004-1704
US

IV. Provider business mailing address

225 E CITY AVE STE 225
BALA CYNWYD PA
19004-1704
US

V. Phone/Fax

Practice location:
  • Phone: 303-319-5980
  • Fax:
Mailing address:
  • Phone: 484-989-8700
  • Fax: 484-562-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: CONOR VICKERS
Title or Position: OWNER
Credential: MD
Phone: 303-319-5980