Provider Demographics
NPI:1275022519
Name:ART OF DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:ART OF DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHETHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-802-1310
Mailing Address - Street 1:28903 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0924
Mailing Address - Country:US
Mailing Address - Phone:248-581-0333
Mailing Address - Fax:
Practice Address - Street 1:28903 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0924
Practice Address - Country:US
Practice Address - Phone:415-802-1310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108548207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty