Provider Demographics
NPI:1336253095
Name:CLAYTON DERMATOLOGY LLC
Entity type:Organization
Organization Name:CLAYTON DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUCIANN
Authorized Official - Middle Name:LISI
Authorized Official - Last Name:HRUZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-645-4500
Mailing Address - Street 1:816 S KIRKWOOD RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6056
Mailing Address - Country:US
Mailing Address - Phone:314-645-4500
Mailing Address - Fax:314-645-5907
Practice Address - Street 1:816 S KIRKWOOD RD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6056
Practice Address - Country:US
Practice Address - Phone:314-645-4500
Practice Address - Fax:314-645-5907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF57539Medicare UPIN