Provider Demographics
NPI:1477931608
Name:WHEATLAND DERMATOLOGY LLC
Entity Type:Organization
Organization Name:WHEATLAND DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-290-8672
Mailing Address - Street 1:1050 EAST GREENVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2622
Mailing Address - Country:US
Mailing Address - Phone:419-394-3331
Mailing Address - Fax:419-394-3330
Practice Address - Street 1:1050 EAST GREENVILLE RD
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-4588
Practice Address - Country:US
Practice Address - Phone:419-394-3331
Practice Address - Fax:419-394-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35120090207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH130662Medicare PIN