Provider Demographics
NPI:1013091115
Name:COMMONWEALTH DERMATOLOGY, PC
Entity Type:Organization
Organization Name:COMMONWEALTH DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAZLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KONERDING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-282-0831
Mailing Address - Street 1:7001 FOREST AVE
Mailing Address - Street 2:STE. 400
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1726
Mailing Address - Country:US
Mailing Address - Phone:804-282-0831
Mailing Address - Fax:804-288-7135
Practice Address - Street 1:7001 FOREST AVE
Practice Address - Street 2:STE. 400
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1726
Practice Address - Country:US
Practice Address - Phone:804-282-0831
Practice Address - Fax:804-288-7135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101026447207N00000X
VA0101233942207N00000X
VA0101238054207ND0101X
VA0101053332207NP0225X
VA0101044250207NP0225X
VA0017137835363LA2100X
VA0017138217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACB6342OtherRAILROAD MEDICARE
VA3118456OtherAETNA GROUP NO.
VA057917OtherANTHEM GROUP NO.
VAC05739Medicare ID - Type Unspecified