MEDICARE: VIRGINIA DERMATOLOGY & SKIN CANCER CENTER PLLC

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	261QM2500X	Medical Specialty Clinic/Center	0101042937	VA

General Provider Information

NPI Number	:	1396774667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRGINIA DERMATOLOGY & SKIN CANCER CENTER PLLC

Provider Business Mailing Address
First Line	:	241 CORPORATE BLVD
Second Line	:	SUITE 215
City	:	NORFOLK
State	:	VA
Zip	:	23502-4954
Country	:	US
Telephone Number	:	757-455-5009
Fax Number	:	757-362-3577

Provider Business Practice Location Address
First Line	:	9724 BAY POINT DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23518-2013
Country	:	US
Telephone Number	:	757-404-7725
Fax Number	:	757-362-3577

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRIAN L. JOHNSON
Credential	:	M.D.
Telephone Number	:	757-455-5009

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	08/22/2020

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