Provider Demographics
NPI:1689076747
Name:VIENNA DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:VIENNA DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAI
Authorized Official - Middle Name:HOANG
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-281-3626
Mailing Address - Street 1:410 MAPLE AVE W STE 3
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4224
Mailing Address - Country:US
Mailing Address - Phone:703-281-3626
Mailing Address - Fax:703-281-3615
Practice Address - Street 1:410 MAPLE AVE W STE 3
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4224
Practice Address - Country:US
Practice Address - Phone:703-281-3626
Practice Address - Fax:703-281-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-20
Last Update Date:2014-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244058261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A948510Medicaid