Provider Demographics
NPI:1477708642
Name:AQUA DERMATOLOGY OF ALABAMA PC
Entity Type:Organization
Organization Name:AQUA DERMATOLOGY OF ALABAMA PC
Other - Org Name:SURGICAL DERMATOLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-977-9786
Mailing Address - Street 1:1940 STONEGATE DR STE 130
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HLS
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2541
Mailing Address - Country:US
Mailing Address - Phone:205-977-9876
Mailing Address - Fax:205-977-9976
Practice Address - Street 1:1940 STONEGATE DR STE 130
Practice Address - Street 2:
Practice Address - City:VESTAVIA HLS
Practice Address - State:AL
Practice Address - Zip Code:35242
Practice Address - Country:US
Practice Address - Phone:205-977-9876
Practice Address - Fax:205-977-9976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20579207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty