Provider Demographics
NPI:1508996430
Name:MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-371-7010
Mailing Address - Street 1:92 MONTVALE AVE
Mailing Address - Street 2:3000
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3647
Mailing Address - Country:US
Mailing Address - Phone:781-438-6350
Mailing Address - Fax:
Practice Address - Street 1:92 HIGH ST
Practice Address - Street 2:T21
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3850
Practice Address - Country:US
Practice Address - Phone:781-391-0778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty