Provider Demographics
NPI:1396906988
Name:CLOVIS DERMATOLOGY PA
Entity type:Organization
Organization Name:CLOVIS DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:575-762-8890
Mailing Address - Street 1:818 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4431
Mailing Address - Country:US
Mailing Address - Phone:575-762-8890
Mailing Address - Fax:
Practice Address - Street 1:818 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4431
Practice Address - Country:US
Practice Address - Phone:575-762-8890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA101294174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM024070OtherBLUE CROSS BLUE SHIELD
NM202005741OtherPRESBYTERIAN HEALTH PLAN
NMF94267Medicare UPIN
NM202005741OtherPRESBYTERIAN HEALTH PLAN