Provider Demographics
NPI:1942201488
Name:CARY DERMATOLOGY CENTER, P.A.
Entity Type:Organization
Organization Name:CARY DERMATOLOGY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-467-8556
Mailing Address - Street 1:101 SW CARY PKWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-5562
Mailing Address - Country:US
Mailing Address - Phone:919-467-8556
Mailing Address - Fax:
Practice Address - Street 1:101 SW CARY PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5562
Practice Address - Country:US
Practice Address - Phone:919-467-8556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0153NOtherBLUE CROSS AND BLUE SHIEL
NC230817Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER