Provider Demographics
NPI:1427297431
Name:DERMATOLOGY CLINIC, P.C.
Entity type:Organization
Organization Name:DERMATOLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-484-8842
Mailing Address - Street 1:3245 INTERNATIONAL CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3152
Mailing Address - Country:US
Mailing Address - Phone:719-484-8840
Mailing Address - Fax:719-484-8845
Practice Address - Street 1:3245 INTERNATIONAL CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3152
Practice Address - Country:US
Practice Address - Phone:719-484-8840
Practice Address - Fax:719-484-8845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98058363Medicaid