Provider Demographics
NPI:1457612491
Name:COLE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:COLE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-241-7546
Mailing Address - Street 1:2410 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2533
Mailing Address - Country:US
Mailing Address - Phone:229-241-7546
Mailing Address - Fax:229-469-5722
Practice Address - Street 1:2410 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2533
Practice Address - Country:US
Practice Address - Phone:229-241-7546
Practice Address - Fax:229-469-5722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065951207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G707908Medicare PIN