Provider Demographics
NPI:1871304337
Name:AGAPE DERAMTOLOGY OF JOHNSTON LLC
Entity type:Organization
Organization Name:AGAPE DERAMTOLOGY OF JOHNSTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLARI
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:401-529-7787
Mailing Address - Street 1:1526 ATWOOD AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3289
Mailing Address - Country:US
Mailing Address - Phone:401-737-7546
Mailing Address - Fax:
Practice Address - Street 1:1526 ATWOOD AVE STE 210
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3289
Practice Address - Country:US
Practice Address - Phone:401-396-2227
Practice Address - Fax:401-421-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty