Basic Information
Provider Information | |||||||||
NPI: | 1053449306 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DERMATOLOGY SPECIALISTS OF BOULDER, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1056 S 88TH ST | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | CO | ||||||||
PostalCode: | 800279460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034426647 | ||||||||
FaxNumber: | 3034422696 | ||||||||
Practice Location | |||||||||
Address1: | 1056 S 88TH ST | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | CO | ||||||||
PostalCode: | 800279460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034426647 | ||||||||
FaxNumber: | 3034422696 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2007 | ||||||||
LastUpdateDate: | 06/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLEN | ||||||||
AuthorizedOfficialFirstName: | SHAWN | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3034426647 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 43816 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   | 207ND0900X | 43816 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207ND0101X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.