Healthcare Provider Details

I. General information

NPI: 1497968945
Provider Name (Legal Business Name): DERMATOLOGY ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 12/07/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18425 W CREEK DR STE F
TINLEY PARK IL
60477-6767
US

IV. Provider business mailing address

18425 W CREEK DR STE F
TINLEY PARK IL
60477-6767
US

V. Phone/Fax

Practice location:
  • Phone: 708-444-8300
  • Fax: 708-444-8301
Mailing address:
  • Phone: 708-444-8300
  • Fax: 708-444-8301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number042618383
License Number StateIL

VIII. Authorized Official

Name: VIVEK IYENGAR
Title or Position: OWNER
Credential:
Phone: 708-444-8300