Provider Demographics
NPI:1255466330
Name:DERMATOLOGY ASSOCIATES OF DOTHAN, LLC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF DOTHAN, LLC
Other - Org Name:TROY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:PYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-793-9222
Mailing Address - Street 1:2431 W MAIN ST STE 501
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1274
Mailing Address - Country:US
Mailing Address - Phone:334-793-9222
Mailing Address - Fax:334-671-0322
Practice Address - Street 1:2431 W MAIN ST
Practice Address - Street 2:STE 501
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301
Practice Address - Country:US
Practice Address - Phone:334-793-9222
Practice Address - Fax:334-671-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA085296164BMedicaid
DG8208OtherRR MEDICARE
AL01D2143273OtherCLIA HUNTSVILLE
AL01D0670555OtherCLIA
AL01D2111151OtherCLIA TROY
AL529922330Medicaid