Healthcare Provider Details

I. General information

NPI: 1861890303
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF FAIRFAX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10680 MAIN ST STE 200
FAIRFAX VA
22030-3810
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 703-352-2620
  • Fax:
Mailing address:
  • Phone: 561-314-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY D. QUEEN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 561-314-2000