MEDICARE: DERMATOLOGY HEALTH SPECIALISTS, 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	207ND0101X	MOHS-Micrographic Surgery Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1447713573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY HEALTH SPECIALISTS, PC

Provider Business Mailing Address
First Line	:	PO BOX 831
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97709-0831
Country	:	US
Telephone Number	:	210-632-5544
Fax Number	:

Provider Business Practice Location Address
First Line	:	1693 SW CHANDLER AVE STE 250
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3231
Country	:	US
Telephone Number	:	210-632-5544
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	OLIVER WISCO
Credential	:	DO
Telephone Number	:	210-632-5544

Provider Enumeration Date	:	04/06/2019
Last Update Date	:	04/06/2019

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