Basic Information
| Provider Information | |||||||||
| NPI: | 1770959520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY ASSOCIATES OF INDY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6966 S UTICA AVE | ||||||||
| Address2: | STE. 225 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554926333 | ||||||||
| FaxNumber: | 9184939405 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 W SMITH VALLEY RD | ||||||||
| Address2: | STE. B | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461421599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554926333 | ||||||||
| FaxNumber: | 9184939405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2015 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | NEVIN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8554926333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.