Basic Information
| Provider Information | |||||||||
| NPI: | 1053493288 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERM ONE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 S COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246051640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763263376 | ||||||||
| FaxNumber: | 2763263046 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 S COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246051640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763263376 | ||||||||
| FaxNumber: | 2763263046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 01/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | TOLLIVER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2763263376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.