MEDICARE: CAPITAL DERMATOLOGY LTD

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	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	5629309	OTHER	AETNA PPO GROUP
2	111874	OTHER	KAISER GROUP
3	0483568	OTHER	AETNA HMO GROUP

General Provider Information

NPI Number	:	1295822419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL DERMATOLOGY LTD

Provider Business Mailing Address
First Line	:	4660 KENMORE AVE STE 500
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-1300
Country	:	US
Telephone Number	:	703-370-0073
Fax Number	:	703-370-2002

Provider Business Practice Location Address
First Line	:	4660 KENMORE AVE STE 500
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-1300
Country	:	US
Telephone Number	:	703-370-0073
Fax Number	:	703-370-2002

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRUCE DAVID GLASSMAN
Credential	:	M.D.
Telephone Number	:	703-370-0073

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	04/01/2011

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Directions to “CAPITAL DERMATOLOGY LTD ” Practice Location

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