Provider Demographics
NPI:1295822419
Name:CAPITAL DERMATOLOGY LTD
Entity Type:Organization
Organization Name:CAPITAL DERMATOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-370-0073
Mailing Address - Street 1:4660 KENMORE AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1300
Mailing Address - Country:US
Mailing Address - Phone:703-370-0073
Mailing Address - Fax:703-370-2002
Practice Address - Street 1:4660 KENMORE AVE STE 500
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1300
Practice Address - Country:US
Practice Address - Phone:703-370-0073
Practice Address - Fax:703-370-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5629309OtherAETNA PPO GROUP
111874OtherKAISER GROUP
0483568OtherAETNA HMO GROUP
5629309OtherAETNA PPO GROUP
DC823601Medicare ID - Type UnspecifiedGROUP