Provider Demographics
NPI:1720089279
Name:BECKLEY DERMATOLOGY INC.
Entity Type:Organization
Organization Name:BECKLEY DERMATOLOGY INC.
Other - Org Name:DERMATOLOGY ASSOCIATES & SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:E
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-252-2673
Mailing Address - Street 1:148 LINDEN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6909
Mailing Address - Country:US
Mailing Address - Phone:540-504-0066
Mailing Address - Fax:540-678-9025
Practice Address - Street 1:94 BROOKSHIRE LANE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6765
Practice Address - Country:US
Practice Address - Phone:304-252-2673
Practice Address - Fax:304-929-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
MD207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD258407700Medicaid
WV1720089279Medicaid
MD553156Medicare PIN
WV1720089279Medicaid