Basic Information
| Provider Information | |||||||||
| NPI: | 1568674133 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DERMATOLOGY CONSULTANTS OF GLOUCESTER P L L C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 693 | ||||||||
| Address2: | |||||||||
| City: | GLOUCESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046936527 | ||||||||
| FaxNumber: | 8046936615 | ||||||||
| Practice Location | |||||||||
| Address1: | 6790 WOOD RIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | GLOUCESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046936527 | ||||||||
| FaxNumber: | 8046936615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 06/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | MUFFELMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8046936527 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101026776 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 141598 | 01 | VA | ANTHEM BCBS GROUP NUMBER | OTHER | CJ9476 | 01 | VA | RAILROAD MEDICARE | OTHER |