Provider Demographics
NPI:1457796641
Name:RENASCANCE DERMATOLOGY PC
Entity Type:Organization
Organization Name:RENASCANCE DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWANA
Authorized Official - Middle Name:RASHAD
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-865-6783
Mailing Address - Street 1:3620 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1756
Mailing Address - Country:US
Mailing Address - Phone:703-865-6783
Mailing Address - Fax:703-865-6784
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 303
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1756
Practice Address - Country:US
Practice Address - Phone:703-865-6783
Practice Address - Fax:703-865-6784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240235207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty