Provider Demographics
NPI:1366561292
Name:SKANDAMIS, GEORGE C (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
Last Name:SKANDAMIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 METRO PL N
Mailing Address - Street 2:SUITE 195
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5325
Mailing Address - Country:US
Mailing Address - Phone:614-602-6455
Mailing Address - Fax:614-259-9944
Practice Address - Street 1:425 METRO PL N
Practice Address - Street 2:SUITE 195
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5325
Practice Address - Country:US
Practice Address - Phone:614-602-6455
Practice Address - Fax:614-259-9944
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430184294390200000X
OH35.091957207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2849725Medicaid
MI5315018697OtherCONTROLLED SUBSTANCE LICE