Healthcare Provider Details

I. General information

NPI: 1396774667
Provider Name (Legal Business Name): VIRGINIA DERMATOLOGY & SKIN CANCER CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9724 BAY POINT DR
NORFOLK VA
23518-2013
US

IV. Provider business mailing address

241 CORPORATE BLVD SUITE 215
NORFOLK VA
23502-4954
US

V. Phone/Fax

Practice location:
  • Phone: 757-404-7725
  • Fax: 757-362-3577
Mailing address:
  • Phone: 757-455-5009
  • Fax: 757-362-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number0101042937
License Number StateVA

VIII. Authorized Official

Name: DR. BRIAN L. JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 757-455-5009