Healthcare Provider Details

I. General information

NPI: 1710479936
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF GLOUCESTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6790 WOOD RIDGE DR
GLOUCESTER VA
23061-4377
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 804-693-6527
  • Fax: 804-693-6615
Mailing address:
  • Phone: 561-314-2000
  • Fax: 561-431-2821

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: MANAGER
Credential:
Phone: 561-314-2000