Provider Demographics
NPI:1912220799
Name:ENCORE DERMATOLOGY
Entity Type:Organization
Organization Name:ENCORE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GWYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONDEREE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-442-1012
Mailing Address - Street 1:4900 GETTYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2520
Mailing Address - Country:US
Mailing Address - Phone:614-442-0100
Mailing Address - Fax:
Practice Address - Street 1:4900 GETTYSBURG RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2520
Practice Address - Country:US
Practice Address - Phone:614-442-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069165261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH070016238Medicare PIN