Provider Demographics
NPI:1801622642
Name:JASPER DERMATOLOGY, LLC
Entity type:Organization
Organization Name:JASPER DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNP/OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLAR
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:205-282-1802
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35502-0290
Mailing Address - Country:US
Mailing Address - Phone:205-282-1802
Mailing Address - Fax:
Practice Address - Street 1:87 19TH ST W STE 200
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-5430
Practice Address - Country:US
Practice Address - Phone:205-282-1802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty