Provider Demographics
NPI:1669971776
Name:SUPER DERMATOLOGY LLC
Entity type:Organization
Organization Name:SUPER DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIONE
Authorized Official - Middle Name:MARCUS
Authorized Official - Last Name:SUPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-285-3533
Mailing Address - Street 1:1351 AUDUBON CT SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-2471
Mailing Address - Country:US
Mailing Address - Phone:706-840-4554
Mailing Address - Fax:
Practice Address - Street 1:1364 WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3872
Practice Address - Country:US
Practice Address - Phone:770-285-3533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-03
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60121207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty