Provider Demographics
NPI:1255946315
Name:CITY SOUTH DERMATOLOGY PLLC
Entity type:Organization
Organization Name:CITY SOUTH DERMATOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GOVERNOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LEE-TSONG
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-412-1987
Mailing Address - Street 1:3715 196TH ST SW UNIT 2058
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-3202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24604 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-5385
Practice Address - Country:US
Practice Address - Phone:617-412-1987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty