Provider Demographics
NPI:1972004455
Name:DERMATOLOGY BY DESIGN LLC
Entity Type:Organization
Organization Name:DERMATOLOGY BY DESIGN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:QUTUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-705-2331
Mailing Address - Street 1:949 NW OVERTON ST UNIT 608
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3270
Mailing Address - Country:US
Mailing Address - Phone:503-705-2331
Mailing Address - Fax:
Practice Address - Street 1:1129 NW 11TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3469
Practice Address - Country:US
Practice Address - Phone:503-705-2331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD158125207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty