Provider Demographics
NPI:1952593832
Name:FDL DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:FDL DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:REGAN
Authorized Official - Last Name:HERBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-310-7400
Mailing Address - Street 1:1715 N GEORGE MASON DR
Mailing Address - Street 2:SUITE 406
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3609
Mailing Address - Country:US
Mailing Address - Phone:703-310-7400
Mailing Address - Fax:703-574-3184
Practice Address - Street 1:1715 N GEORGE MASON DR
Practice Address - Street 2:SUITE 406
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3609
Practice Address - Country:US
Practice Address - Phone:703-310-7400
Practice Address - Fax:703-574-3184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241553207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G02678Medicare PIN
DH2066Medicare PIN