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General NPI Number Information
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NPI Number | 1144496613
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Entity Type | Organization
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Legal Business Name | ISLAND COUNTY DERMATOLOGY, PLLC
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Dates
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Enumeration Date | 05/05/2008
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Last Update Date | 11/01/2010
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Provider Practice Location Address
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Address Line | 3110 COMMERCIAL AVE STE 105
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City | ANACORTES
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State | WA
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Zip | 98221-2762
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Country | US
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Telephone | 360-588-0613
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Fax |
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Provider Business Mailing Address
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Address Line | 3110 COMMERCIAL AVE STE 105
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City | ANACORTES
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State | WA
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Zip | 98221-2762
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Country | US
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Telephone | 360-588-0613
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DONALD RUSSELL JOHNSON
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Credential | MD PHD
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Telephone | 360-588-0613
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | MD00038058
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License Number State | WA
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