Basic Information
| Provider Information | |||||||||
| NPI: | 1477931608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHEATLAND DERMATOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1165 S KNOXVILLE AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943331 | ||||||||
| FaxNumber: | 4193943330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 S KNOXVILLE AVE STE A | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943332 | ||||||||
| FaxNumber: | 8285868209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2015 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | QUINTER | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4192908672 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 35120090 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.