Provider Demographics
NPI:1255791448
Name:DERMATOLOGY ASSOCIATES OF NORTHERN VIRGINIA
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF NORTHERN VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:NEELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-222-2773
Mailing Address - Street 1:13880 BRADDOCK RD STE 301
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2462
Mailing Address - Country:US
Mailing Address - Phone:703-222-2773
Mailing Address - Fax:703-222-6093
Practice Address - Street 1:25055 RIDING PLZ
Practice Address - Street 2:SUITE 230
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-5917
Practice Address - Country:US
Practice Address - Phone:703-222-2773
Practice Address - Fax:703-222-6093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047432305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization