Provider Demographics
NPI:1104944032
Name:DERMEDX DERMATOLOGY PC
Entity type:Organization
Organization Name:DERMEDX DERMATOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, JD
Authorized Official - Phone:631-265-1351
Mailing Address - Street 1:222 E MAIN ST
Mailing Address - Street 2:SUITE 228
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2871
Mailing Address - Country:US
Mailing Address - Phone:631-265-1351
Mailing Address - Fax:631-265-9363
Practice Address - Street 1:222 E MAIN ST
Practice Address - Street 2:SUITE 228
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2871
Practice Address - Country:US
Practice Address - Phone:631-265-1351
Practice Address - Fax:631-265-9363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195658174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1740242031OtherNPI
NY01785368Medicaid
NY110501OtherMEDICARE INDIVIDUAL #
NYW17942OtherMEDICARE GROUP #
NY110501OtherMEDICARE INDIVIDUAL #