Provider Demographics
NPI:1891812848
Name:DERMATOLOGY ASSOCIATES OF FREDERICKSBURG
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF FREDERICKSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-373-1080
Mailing Address - Street 1:2301 FALL HILL AVE
Mailing Address - Street 2:SUITE106
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3349
Mailing Address - Country:US
Mailing Address - Phone:540-373-1080
Mailing Address - Fax:540-373-1094
Practice Address - Street 1:2301 FALL HILL AVE
Practice Address - Street 2:SUITE106
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3349
Practice Address - Country:US
Practice Address - Phone:540-373-1080
Practice Address - Fax:540-373-1094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027880174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA100699OtherANTHEM BLUECROSS
VA005900425Medicaid