=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376240234
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIRECT DERMATOLOGY & AESTHETICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2023
-----------------------------------------------------
Last Update Date | 02/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48766 STONERIDGE DR
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-8675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-615-6569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48766 STONERIDGE DR
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-8675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-615-6569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DERMATOLOGIST
-----------------------------------------------------
Name | DR. FARHAAD RIYAZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 703-615-6569
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207NI0002X
-----------------------------------------------------
Taxonomy Name | Clinical & Laboratory Dermatological Immunology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207NP0225X
-----------------------------------------------------
Taxonomy Name | Pediatric Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------