Provider Demographics
NPI:1821093550
Name:VALLEY DERMATOLOGY CENTER, INC.
Entity Type:Organization
Organization Name:VALLEY DERMATOLOGY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-357-2800
Mailing Address - Street 1:851 WESTPOINT DR
Mailing Address - Street 2:STE B10
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7191
Mailing Address - Country:US
Mailing Address - Phone:907-357-2800
Mailing Address - Fax:907-357-2801
Practice Address - Street 1:851 WESTPOINT DR
Practice Address - Street 2:STE B10
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7191
Practice Address - Country:US
Practice Address - Phone:907-357-2800
Practice Address - Fax:907-357-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK291762207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK152340Medicare ID - Type UnspecifiedALASKA MEDICARE