Basic Information
| Provider Information | |||||||||
| NPI: | 1730104381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOORESTOWN DERMATOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 MARTER AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562356565 | ||||||||
| FaxNumber: | 8562356566 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 MARTER AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562356565 | ||||||||
| FaxNumber: | 8562356566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 08/31/2015 | ||||||||
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| AuthorizedOfficialLastName: | CAMISHION | ||||||||
| AuthorizedOfficialFirstName: | GERMAINE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8562356565 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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.