Basic Information
Provider Information | |||||||||
NPI: | 1285255786 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ARTIUS DERMATOLOGY ASSOCIATES PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 101868 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911890055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9564573809 | ||||||||
FaxNumber: | 9568030711 | ||||||||
Practice Location | |||||||||
Address1: | 653 N TOWN CENTER DR STE 512 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891440519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7027967546 | ||||||||
FaxNumber: | 7028596146 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/06/2020 | ||||||||
LastUpdateDate: | 05/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MISTAK | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3612481505 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
No ID Information.