Provider Demographics
NPI:1023515277
Name:VIBRANT DERMATOLOGY PLLC
Entity type:Organization
Organization Name:VIBRANT DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:IMAHIYEROBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-840-9034
Mailing Address - Street 1:226 DEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-1566
Mailing Address - Country:US
Mailing Address - Phone:617-840-9034
Mailing Address - Fax:
Practice Address - Street 1:588 PROVIDENCE HWY
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-6804
Practice Address - Country:US
Practice Address - Phone:781-708-9299
Practice Address - Fax:855-699-6813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254815207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110098002AMedicaid