Provider Demographics
NPI:1083012355
Name:MONTGOMERY DERMATOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MONTGOMERY DERMATOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:J
Authorized Official - Last Name:GIBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-216-2983
Mailing Address - Street 1:15225 SHADY GROVE RD
Mailing Address - Street 2:STE. 303
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3254
Mailing Address - Country:US
Mailing Address - Phone:301-216-2980
Mailing Address - Fax:301-216-2982
Practice Address - Street 1:15225 SHADY GROVE RD
Practice Address - Street 2:STE. 303
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3254
Practice Address - Country:US
Practice Address - Phone:301-216-2980
Practice Address - Fax:301-216-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042867261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty