=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144493396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY DERMATOLOGY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2008
-----------------------------------------------------
Last Update Date | 05/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 BEAVER RUIN RD NW SUITE B
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-3401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-921-4300
-----------------------------------------------------
Fax | 770-381-6451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 BEAVER RUIN RD NW SUITE B
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-3401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-921-4300
-----------------------------------------------------
Fax | 770-381-6451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DELE YUDOWI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-231-5279
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------