Provider Demographics
NPI:1659115145
Name:EXPERIENCE DERMATOLOGY LLC
Entity type:Organization
Organization Name:EXPERIENCE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:EYRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:801-822-8565
Mailing Address - Street 1:17 EXECUTIVE PARK DR NE STE 115
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2222
Mailing Address - Country:US
Mailing Address - Phone:404-737-2333
Mailing Address - Fax:404-737-2444
Practice Address - Street 1:17 EXECUTIVE PARK DR NE STE 115
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2222
Practice Address - Country:US
Practice Address - Phone:404-737-2333
Practice Address - Fax:404-737-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty