Basic Information
| Provider Information | |||||||||
| NPI: | 1669971776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUPER DERMATOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 AUDUBON CT SW | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303112471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068404554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1364 WELLBROOK CIR NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702853533 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2018 | ||||||||
| LastUpdateDate: | 02/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | SUPER | ||||||||
| AuthorizedOfficialFirstName: | DIONE | ||||||||
| AuthorizedOfficialMiddleName: | MARCUS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7702853533 | ||||||||
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| 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 | 60121 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.