Healthcare Provider Details

I. General information

NPI: 1225127244
Provider Name (Legal Business Name): DEERFIELD DERMATOLOGY ASSOCIATES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 LAKE COOK RD SUITE #280
DEERFIELD IL
60015-4909
US

IV. Provider business mailing address

707 LAKE COOK RD SUITE #280
DEERFIELD IL
60015-4909
US

V. Phone/Fax

Practice location:
  • Phone: 847-480-0004
  • Fax: 847-480-8707
Mailing address:
  • Phone: 847-480-0004
  • Fax: 847-480-8707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number042-618435
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA GOTTFREDSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 847-480-0004