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General NPI Number Information
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NPI Number | 1790178010
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Entity Type | Organization
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Legal Business Name | MODERN DERMATOLOGY, PLLC
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Dates
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Enumeration Date | 03/11/2015
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Last Update Date | 08/04/2022
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Provider Practice Location Address
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Address Line | 1021 MERCER ST
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City | SEATTLE
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State | WA
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Zip | 98109
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Country | US
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Telephone | 206-486-2982
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Fax | 206-973-5380
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Provider Business Mailing Address
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Address Line | 1021 MERCER ST
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City | SEATTLE
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State | WA
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Zip | 98109
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Country | US
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Telephone | 205-489-3206
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Fax | 206-973-5380
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Authorized Official
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Title or Position | OWNER
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Name | DR. HEATHER D ROGERS
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Credential | MD
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Telephone | 206-486-2982
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 60048520
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License Number State | WA
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