Healthcare Provider Details

I. General information

NPI: 1720089279
Provider Name (Legal Business Name): BECKLEY DERMATOLOGY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 BROOKSHIRE LANE
BECKLEY WV
25801-6765
US

IV. Provider business mailing address

148 LINDEN DR SUITE 101
WINCHESTER VA
22601-6909
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-2673
  • Fax: 304-929-2350
Mailing address:
  • Phone: 540-504-0066
  • Fax: 540-678-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateWV

VIII. Authorized Official

Name: MR. NELSON E. VELAZQUEZ
Title or Position: SOLE OWNER
Credential: DO
Phone: 304-252-2673