Provider Demographics
NPI:1194209163
Name:LIVE OAK DERMATOLOGY
Entity Type:Organization
Organization Name:LIVE OAK DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEDJEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-870-2020
Mailing Address - Street 1:135 NORCROSS ST # 8
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3867
Mailing Address - Country:US
Mailing Address - Phone:678-870-2020
Mailing Address - Fax:
Practice Address - Street 1:135 NORCROSS ST # 8
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3867
Practice Address - Country:US
Practice Address - Phone:678-870-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty