Provider Demographics
NPI:1750703666
Name:DERMATOLOGIC AND MOHS SURGERY CONSULTANTS LLC
Entity type:Organization
Organization Name:DERMATOLOGIC AND MOHS SURGERY CONSULTANTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-363-4190
Mailing Address - Street 1:101 CANDLEWOOD CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2654
Mailing Address - Country:US
Mailing Address - Phone:434-363-4190
Mailing Address - Fax:434-363-4191
Practice Address - Street 1:101 CANDLEWOOD CT
Practice Address - Street 2:SUITE 201
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2654
Practice Address - Country:US
Practice Address - Phone:434-363-4190
Practice Address - Fax:434-363-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-11
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101248532207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD372Medicare PIN