Provider Demographics
NPI:1649281320
Name:ISLAND COUNTY DERMATOLOGY PLLC
Entity type:Organization
Organization Name:ISLAND COUNTY DERMATOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:360-678-6561
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-0900
Mailing Address - Country:US
Mailing Address - Phone:360-678-6561
Mailing Address - Fax:360-678-7133
Practice Address - Street 1:205 S MAIN ST
Practice Address - Street 2:BLG A
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-9500
Practice Address - Country:US
Practice Address - Phone:360-678-6561
Practice Address - Fax:360-678-7133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038058207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1108877Medicaid
WA1598790990OtherNPI
WAG88409Medicare UPIN
WA1598790990OtherNPI
WA1108877Medicaid
WAG8856648Medicare PIN