=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215990700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DERMATOLOGY AND SKIN SURGERY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2006
-----------------------------------------------------
Last Update Date | 03/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 MEDICAL PARK DR
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28803-2493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-274-4880
-----------------------------------------------------
Fax | 828-274-6868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 MEDICAL PARK DR
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28803-2493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-274-4880
-----------------------------------------------------
Fax | 828-274-6868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DANIEL ISRAEL ZIVONY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 828-274-4880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 200201027
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | 200201027
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 200201027
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------