Healthcare Provider Details

I. General information

NPI: 1740752880
Provider Name (Legal Business Name): BECKLEY DERMATOLOGY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2018
Last Update Date: 12/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PROSPERITY LN STE 207
LOGAN WV
25601-3743
US

IV. Provider business mailing address

136 LINDEN DR STE 104
WINCHESTER VA
22601-6900
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-8202
  • Fax: 304-752-0050
Mailing address:
  • Phone: 540-678-3588
  • Fax: 540-678-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

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