Provider Demographics
NPI:1063576148
Name:ANIMAS DERMATOLOGY MD PC
Entity type:Organization
Organization Name:ANIMAS DERMATOLOGY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-324-8375
Mailing Address - Street 1:1654 COUNTY ROAD 120
Mailing Address - Street 2:
Mailing Address - City:HESPERUS
Mailing Address - State:CO
Mailing Address - Zip Code:81326-9752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4801 N BUTLER AVE STE 9101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3300
Practice Address - Country:US
Practice Address - Phone:505-324-8375
Practice Address - Fax:505-327-4638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM012425OtherBLUE CROSS BLUE SHIELD NM
NMQ2833Medicaid
CO=========-001OtherROCKY MT HMO
NMNM012425OtherBLUE CROSS BLUE SHIELD NM