Healthcare Provider Details

I. General information

NPI: 1750703666
Provider Name (Legal Business Name): DERMATOLOGIC AND MOHS SURGERY CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2014
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CANDLEWOOD CT SUITE 201
LYNCHBURG VA
24502-2654
US

IV. Provider business mailing address

101 CANDLEWOOD CT SUITE 201
LYNCHBURG VA
24502-2654
US

V. Phone/Fax

Practice location:
  • Phone: 434-363-4190
  • Fax: 434-363-4191
Mailing address:
  • Phone: 434-363-4190
  • Fax: 434-363-4191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number0101248532
License Number StateVA

VIII. Authorized Official

Name: DR. JASON D GIVAN
Title or Position: OWNER
Credential: M.D.
Phone: 434-363-4190