Healthcare Provider Details

I. General information

NPI: 1790178010
Provider Name (Legal Business Name): MODERN DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 MERCER ST
SEATTLE WA
98109
US

IV. Provider business mailing address

1021 MERCER ST
SEATTLE WA
98109
US

V. Phone/Fax

Practice location:
  • Phone: 206-486-2982
  • Fax: 206-973-5380
Mailing address:
  • Phone: 205-489-3206
  • Fax: 206-973-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number60048520
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. HEATHER D ROGERS
Title or Position: OWNER
Credential: MD
Phone: 206-486-2982