Provider Demographics
NPI:1902428709
Name:CLINICAL DERMATOLOGY CENTER, LLC
Entity Type:Organization
Organization Name:CLINICAL DERMATOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAVLOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-371-6302
Mailing Address - Street 1:14500 AVION PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1108
Mailing Address - Country:US
Mailing Address - Phone:703-705-7000
Mailing Address - Fax:703-763-7255
Practice Address - Street 1:14500 AVION PKWY STE 100
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1108
Practice Address - Country:US
Practice Address - Phone:703-705-7000
Practice Address - Fax:703-763-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578682894OtherINDIVIDUAL NPI