Provider Demographics
NPI:1598964348
Name:DERMATOLOGY & SKIN SURGERY CENTER. P.C.
Entity Type:Organization
Organization Name:DERMATOLOGY & SKIN SURGERY CENTER. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUJICA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-474-5952
Mailing Address - Street 1:210 VILLAGE CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9044
Mailing Address - Country:US
Mailing Address - Phone:770-474-5952
Mailing Address - Fax:770-474-1300
Practice Address - Street 1:210 VILLAGE CENTER PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9044
Practice Address - Country:US
Practice Address - Phone:770-474-5952
Practice Address - Fax:770-474-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherEIN NUMBER
GACA9936Medicare PIN
GA=========OtherEIN NUMBER