Provider Demographics
NPI:1669716395
Name:VISAGE DERMATOLOGY AND AESTHETIC CENTER, LLC
Entity type:Organization
Organization Name:VISAGE DERMATOLOGY AND AESTHETIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. SURIN-LORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-223-3533
Mailing Address - Street 1:PO BOX 7224
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20792-7224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 MERCANTILE LN
Practice Address - Street 2:SUITE 110
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5341
Practice Address - Country:US
Practice Address - Phone:240-223-3533
Practice Address - Fax:240-465-4800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065513207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty