Provider Demographics
NPI:1144496613
Name:ISLAND COUNTY DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:ISLAND COUNTY DERMATOLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:360-588-0613
Mailing Address - Street 1:3110 COMMERCIAL AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2762
Mailing Address - Country:US
Mailing Address - Phone:360-588-0613
Mailing Address - Fax:
Practice Address - Street 1:3110 COMMERCIAL AVE STE 105
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2762
Practice Address - Country:US
Practice Address - Phone:360-588-0613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038058261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8856648Medicare PIN