Healthcare Provider Details

I. General information

NPI: 1043462591
Provider Name (Legal Business Name): DERMATOLOGY OFFICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W HARPER ST
POPLAR BLUFF MO
63901-4119
US

IV. Provider business mailing address

1600 W HARPER ST
POPLAR BLUFF MO
63901-4119
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4750
  • Fax: 573-686-4753
Mailing address:
  • Phone: 573-686-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: VANESSA ADAMS
Title or Position: OWNER/PROVIDER
Credential:
Phone: 573-686-4750