Provider Demographics
NPI:1780658203
Name:DERMATOLOGY SPECIALISTS OF W GA
Entity type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF W GA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:JO
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-838-9333
Mailing Address - Street 1:109 PROFESSIONAL PLACE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3862
Mailing Address - Country:US
Mailing Address - Phone:770-838-9333
Mailing Address - Fax:770-838-7755
Practice Address - Street 1:109 PROFESSIONAL PLACE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3862
Practice Address - Country:US
Practice Address - Phone:770-838-9333
Practice Address - Fax:770-838-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5021Medicare ID - Type UnspecifiedMEDICARE GROUP #