Healthcare Provider Details

I. General information

NPI: 1053449306
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS OF BOULDER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 S 88TH ST
LOUISVILLE CO
80027-9460
US

IV. Provider business mailing address

1056 S 88TH ST
LOUISVILLE CO
80027-9460
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-6647
  • Fax: 303-442-2696
Mailing address:
  • Phone: 303-442-6647
  • Fax: 303-442-2696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number43816
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number43816
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAWN B ALLEN
Title or Position: PRESIDENT
Credential: MD
Phone: 303-442-6647