Provider Demographics
NPI:1780052811
Name:DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.
Entity type:Organization
Organization Name:DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEPAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-433-7536
Mailing Address - Street 1:5300 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2381
Mailing Address - Country:US
Mailing Address - Phone:937-433-7536
Mailing Address - Fax:937-433-9612
Practice Address - Street 1:7691 5 MILE RD
Practice Address - Street 2:SUITE 312
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4348
Practice Address - Country:US
Practice Address - Phone:513-232-3332
Practice Address - Fax:513-232-9635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-06
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty