Basic Information
| Provider Information | |||||||||
| NPI: | 1144278441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY DERMATOLOGY, PS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 565 EUREKA WAY | ||||||||
| Address2: | |||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983825074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605820808 | ||||||||
| FaxNumber: | 3606835678 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 EUREKA WAY | ||||||||
| Address2: | |||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983825074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605820808 | ||||||||
| FaxNumber: | 3606835678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 01/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | HAYCOX | ||||||||
| AuthorizedOfficialFirstName: | CLAIRE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3605820808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD., PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD00035129 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 7111479 | 05 | WA | MEDICAID |