Basic Information
| Provider Information | |||||||||
| NPI: | 1255818522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELMARVA SKIN PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12444 COLLINS RD | ||||||||
| Address2: | |||||||||
| City: | BISHOPVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218131546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815136332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 38394 DUPONT BLVD UNIT FG | ||||||||
| Address2: | |||||||||
| City: | SELBYVILLE | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199753049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3025640001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2018 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | MOGHADDAM | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3025640001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | C1-0011369 | DE | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.