MEDICARE: WOODSTOCK DERMATOLOGY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	32512	GA

General Provider Information

NPI Number	:	1063422251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODSTOCK DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	300 PARKBROOKE PL STE 360
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-7280
Country	:	US
Telephone Number	:	770-924-2573
Fax Number	:	770-924-2534

Provider Business Practice Location Address
First Line	:	300 PARKBROOKE PL
Second Line	:	SUITE 360
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-7209
Country	:	US
Telephone Number	:	770-924-2573
Fax Number	:	770-924-2534

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ANITA WADDELL
Credential	:
Telephone Number	:	770-924-2573

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	02/09/2026

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