NPIMap

Organization Active NPI

Aesthetic Dermatology and Dermatologic Surgery Center

  • Specialist
  • Bowie, MD
National Provider Identifier
1104068790
Registry record updated Aug 27, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
D0051777 Issued in MD
Legal business name
AESTHETIC DERMATOLOGY AND DERMATOLOGIC SURGERY CENTER
Practice address
4321 Collington Rd
Suite 230
Bowie, MD 20716
Phone
(301) 809-4321
Fax
(301) 809-5798
NPI assigned
Mar 30, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 27, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Debra A Coats-Walton, MDNPI 1346295219
Title
Medical Director
Phone
(301) 809-4321

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X D0051777 MD Primary

Addresses

Primary practice location

4321 Collington Rd
Suite 230
Bowie, MD 20716

Mailing address

4321 Collington Rd
Suite 230
Bowie, MD 20716-2259
Phone (301) 809-4321

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in DC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180814001070 DC Part B Supplier - Clinic/Group Practice 0244589968 Receives reassigned benefits from 1 practitioner
Practice locations: Bowie, MD

National Provider Directory

National Provider Directory

Locations

4321 Collington Rd
Ste 230
Bowie, MD 20716
Phone (301) 809-4321

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/17854/brand/1/csg/1/fhir/r4

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1238371200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1535328000000",
    "number": "1104068790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4321 COLLINGTON RD",
            "address_2": "SUITE 230",
            "city": "BOWIE",
            "state": "MD",
            "postal_code": "207162259",
            "telephone_number": "301-809-4321",
            "fax_number": "301-809-5798"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4321 COLLINGTON RD",
            "address_2": "SUITE 230",
            "city": "BOWIE",
            "state": "MD",
            "postal_code": "20716",
            "telephone_number": "301-809-4321",
            "fax_number": "301-809-5798"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AESTHETIC DERMATOLOGY AND DERMATOLOGIC SURGERY CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-03-30",
        "last_updated": "2018-08-27",
        "status": "A",
        "authorized_official_last_name": "COATS-WALTON",
        "authorized_official_first_name": "DEBRA",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "301-809-4321",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "MD",
            "license": "D0051777",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bowie, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 27, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.