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General NPI Number Information
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NPI Number | 1427128511
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Entity Type | Organization
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Legal Business Name | DERMATOLGY & DERMATOLOGIC SURGERY PC
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1021 W OAKLAND DR SUITE 102
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City | JOHNSON CITY
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State | TN
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Zip | 37604-0000
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Country | US
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Telephone | 423-928-9014
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Fax | 423-928-3559
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Provider Business Mailing Address
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Address Line | 1021 W OAKLAND AVE SUITE 102
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City | JOHNSON CITY
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State | TN
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Zip | 37604-2191
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Country | US
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Telephone | 423-928-9014
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Fax | 423-928-3559
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Authorized Official
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Title or Position | DERMATOLOGIST PRESIDENT
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Name | LARRY DAVID HUDSON
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Credential | MD
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Telephone | 423-928-9014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | MD0000013019
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License Number State | TN
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