Basic Information
| Provider Information | |||||||||
| NPI: | 1861890303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED DERMATOLOGY OF FAIRFAX, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 EXCHANGE CT STE 110 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334314450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10721 MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220306913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033522620 | ||||||||
| FaxNumber: | 7033522594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2014 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | QUEEN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5613142000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.