Provider Demographics
NPI:1487720264
Name:SANFORD DERMATOLOGY, PA
Entity type:Organization
Organization Name:SANFORD DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHEESBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-775-7926
Mailing Address - Street 1:827 S HORNER BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-5342
Mailing Address - Country:US
Mailing Address - Phone:919-775-7926
Mailing Address - Fax:919-718-0092
Practice Address - Street 1:827 S HORNER BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5342
Practice Address - Country:US
Practice Address - Phone:919-775-7926
Practice Address - Fax:919-718-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-25
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21635174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8922235Medicaid
NC8922235Medicaid
NC1298Medicare PIN