Basic Information
Provider Information | |||||||||
NPI: | 1811590433 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED DERMATOLOGY SKIN CANCER & LASER SURGERY CENTER P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3464 S. WILLOW STREET | ||||||||
Address2: | SUITE 194 | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802314531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037552900 | ||||||||
FaxNumber: | 3037550404 | ||||||||
Practice Location | |||||||||
Address1: | 2352 MEADOWS BLVD | ||||||||
Address2: | STE 220 | ||||||||
City: | CASTLE ROCK | ||||||||
State: | CO | ||||||||
PostalCode: | 801098416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034931910 | ||||||||
FaxNumber: | 3034931915 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2020 | ||||||||
LastUpdateDate: | 11/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAPADEAS | ||||||||
AuthorizedOfficialFirstName: | GREGORY | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | DOCTOR OF OSTEOPATHIC MEDICINE | ||||||||
AuthorizedOfficialTelephone: | 3036388611 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O | ||||||||
NPICertificationDate: | 11/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.