Southern Dermatology PC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

045299 Issued in GA

Legal business name

SOUTHERN DERMATOLOGY PC

Practice address

1805 Herrington Rd
Building 3, Suite a
Lawrenceville, GA 30043-7987

Phone

(770) 817-2592

Fax

(678) 377-8167

NPI assigned

Aug 2, 2011

Organization subpart

No

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

Authorized official

Name

Dr. Winfred Derrick Moody, M.D.NPI 1124000187

Title

Owner

Phone

(770) 817-2592

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

Locations

Practitioners 2

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

• Winfred Derrick Moody, MD

  • Dermatology Physician
  • Lawrenceville, GA
  • NPI 1124000187
  Medicare reassignment Authorized official
• Thomas Poshia Suitt, D.M.D

  • General Practice Dentistry
  • Atlanta, GA
  • NPI 1760897490
  NPD

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

{
    "created_epoch": "1312243200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1317168000000",
    "number": "1437437837",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1805 HERRINGTON RD",
            "address_2": "BUILDING 3, SUITE A",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300437987",
            "telephone_number": "770-817-2592",
            "fax_number": "678-377-8167"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1805 HERRINGTON RD",
            "address_2": "BUILDING 3, SUITE A",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300437987",
            "telephone_number": "770-817-2592",
            "fax_number": "678-377-8167"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN DERMATOLOGY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-08-02",
        "last_updated": "2011-09-28",
        "status": "A",
        "authorized_official_last_name": "MOODY",
        "authorized_official_first_name": "WINFRED",
        "authorized_official_middle_name": "DERRICK",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "770-817-2592",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "GA",
            "license": "045299",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Luz Melania Soto Garcia, MA
• Maria B. Soto, M.D.
• Soulcare Health, LLC
• Southern Charm Anesthesia Associates
• Southern Clinical Laboratory Inc.
• Southern Endoscopy Suite, LLC
• Southern Gastroenterology Associates, LLC
• Southern Sky Outpatient Detox, LLC
• Southern Smiles Lawrenceville PC
• Southern Surgical Associates, PC

• Dermatology Physician in Lawrenceville, GA
• Providers in Lawrenceville, GA by specialty
• Dermatology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2011; 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.