Provider Demographics
NPI:1467832881
Name:SKIN WELLNESS DERMATOLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:SKIN WELLNESS DERMATOLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-294-9440
Mailing Address - Street 1:245 EAST NC HWY 54
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-2150
Mailing Address - Country:US
Mailing Address - Phone:919-294-9440
Mailing Address - Fax:919-237-3899
Practice Address - Street 1:245 EAST NC HIGHWAY 54
Practice Address - Street 2:STE 202
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-2150
Practice Address - Country:US
Practice Address - Phone:919-294-9440
Practice Address - Fax:919-237-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-00616207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty