Provider Demographics
NPI:1508046293
Name:PRINCE WILLIAM DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:PRINCE WILLIAM DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CUONG
Authorized Official - Middle Name:T
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:571-261-1234
Mailing Address - Street 1:7051 HEATHCOTE VILLAGE WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:571-261-1234
Mailing Address - Fax:571-261-2235
Practice Address - Street 1:7051 HEATHCOTE VILLAGE WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:571-261-1234
Practice Address - Fax:571-261-2235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234235174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH89379Medicare UPIN
VA00V473P48Medicare PIN