Provider Demographics
NPI:1619054525
Name:TIDEWAY DERMATOLOGY, PA
Entity Type:Organization
Organization Name:TIDEWAY DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-939-0961
Mailing Address - Street 1:323 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3201
Mailing Address - Country:US
Mailing Address - Phone:410-939-0961
Mailing Address - Fax:
Practice Address - Street 1:323 S UNION AVE
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3201
Practice Address - Country:US
Practice Address - Phone:410-939-0961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0045614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF77182Medicare UPIN