Provider Demographics
NPI:1396778205
Name:WARRENTON DERMATOLOGY PC
Entity type:Organization
Organization Name:WARRENTON DERMATOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JUAN-CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:CABALLERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-341-1900
Mailing Address - Street 1:28 BLACKWELL PARK LN
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2685
Mailing Address - Country:US
Mailing Address - Phone:540-341-1900
Mailing Address - Fax:540-341-0940
Practice Address - Street 1:28 BLACKWELL PARK LN
Practice Address - Street 2:SUITE 302
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2685
Practice Address - Country:US
Practice Address - Phone:540-341-1900
Practice Address - Fax:540-341-0940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051160174400000X
207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06415Medicare PIN