Provider Demographics
NPI:1790989291
Name:ATHENS-OCONEE SKIN CANCER & DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:ATHENS-OCONEE SKIN CANCER & DERMATOLOGY, LLC
Other - Org Name:OCONEE DERMATOPATHOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:MARIES
Authorized Official - Last Name:BULENGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-769-7546
Mailing Address - Street 1:1582 MARS HILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-4836
Mailing Address - Country:US
Mailing Address - Phone:706-769-7546
Mailing Address - Fax:706-769-2443
Practice Address - Street 1:1582 MARS HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-4836
Practice Address - Country:US
Practice Address - Phone:706-769-7546
Practice Address - Fax:706-769-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050931207N00000X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA050931OtherLICENSE
1194717447OtherNPI INDIVIDUAL
GA050931OtherLICENSE