Provider Demographics
NPI:1801185681
Name:DERMATOLOGY AND SKIN SURGERY CENTER-NEWARK LLC
Entity Type:Organization
Organization Name:DERMATOLOGY AND SKIN SURGERY CENTER-NEWARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-824-4258
Mailing Address - Street 1:175 E DESHLER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2623
Mailing Address - Country:US
Mailing Address - Phone:614-824-4258
Mailing Address - Fax:614-443-3578
Practice Address - Street 1:71 S TERRACE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1355
Practice Address - Country:US
Practice Address - Phone:614-595-0718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-047090207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty