Provider Demographics
NPI:1720284946
Name:THE DERMATOLOGY CLINIC, PLLC
Entity Type:Organization
Organization Name:THE DERMATOLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WINGFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-864-3300
Mailing Address - Street 1:P.O. BOX 6625
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6625
Mailing Address - Country:US
Mailing Address - Phone:228-864-3300
Mailing Address - Fax:228-864-3333
Practice Address - Street 1:11295 EAST TAYLOR ROAD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-864-3300
Practice Address - Fax:228-864-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17831174400000X
207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
25D1013637OtherCLIA
MS06375287Medicaid
MS00874879Medicaid
=========OtherTAX ID
25D1013637OtherCLIA