Provider Demographics
NPI:1790178010
Name:MODERN DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:MODERN DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-486-2982
Mailing Address - Street 1:1021 MERCER ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109
Mailing Address - Country:US
Mailing Address - Phone:205-489-3206
Mailing Address - Fax:206-973-5380
Practice Address - Street 1:1021 MERCER ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109
Practice Address - Country:US
Practice Address - Phone:206-486-2982
Practice Address - Fax:206-973-5380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60048520207N00000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty