Provider Demographics
NPI:1437414703
Name:DERMATOLOGY PRACTICE OF ROANOKE PC
Entity Type:Organization
Organization Name:DERMATOLOGY PRACTICE OF ROANOKE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-323-5035
Mailing Address - Street 1:PO BOX 8734
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1664
Practice Address - Country:US
Practice Address - Phone:540-427-7858
Practice Address - Fax:540-427-7878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252185207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty