Healthcare Provider Details

I. General information

NPI: 1619263407
Provider Name (Legal Business Name): RENEWAL DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7512 GARDNER PARK DR
GAINESVILLE VA
20155-3414
US

IV. Provider business mailing address

7512 GARDNER PARK DR
GAINESVILLE VA
20155-3414
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-9860
  • Fax: 703-753-9863
Mailing address:
  • Phone: 703-753-9860
  • Fax: 703-753-9863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOANNE GUTLIPH
Title or Position: PRESIDENT
Credential: MD
Phone: 571-261-2885