Healthcare Provider Details

I. General information

NPI: 1023171105
Provider Name (Legal Business Name): VIRGINIA SKIN & VEIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 ELECTRIC RD STE C 419 OFFICE CENTER
ROANOKE VA
24018-4561
US

IV. Provider business mailing address

3825 ELECTRIC RD STE C 419 OFFICE CENTER
ROANOKE VA
24018-4561
US

V. Phone/Fax

Practice location:
  • Phone: 540-777-1711
  • Fax: 540-777-1713
Mailing address:
  • Phone: 540-777-1711
  • Fax: 540-777-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number0102050098
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0102050098
License Number StateVA

VIII. Authorized Official

Name: MARTIN T. SMITH
Title or Position: SOLE MEMBER
Credential: DO
Phone: 540-777-1711