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General NPI Number Information
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NPI Number | 1285999490
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Entity Type | Organization
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Legal Business Name | RIVA AESTHETIC DERMATOLOGY, PLLC
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Dates
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Enumeration Date | 07/13/2012
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Last Update Date | 07/13/2012
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Provider Practice Location Address
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Address Line | 17039 KENTON DR SUITE 100
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City | CORNELIUS
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State | NC
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Zip | 28031-5775
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Country | US
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Telephone | 704-607-1518
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Fax |
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Provider Business Mailing Address
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Address Line | 17039 KENTON DR SUITE 100
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City | CORNELIUS
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State | NC
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Zip | 28031-5775
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING PHYSICIAN
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Name | DR. KERRY MARK SHAFRAN
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Credential | M.D.
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Telephone | 704-607-1518
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 39997
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License Number State | NC
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