Provider Demographics
NPI:1548213606
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:STE. 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:781-279-0430
Practice Address - Street 1:92 MONTVALE AVE STE 3000
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3658
Practice Address - Country:US
Practice Address - Phone:781-438-6350
Practice Address - Fax:781-279-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty