Healthcare Provider Details

I. General information

NPI: 1336253095
Provider Name (Legal Business Name): CLAYTON DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 S KIRKWOOD RD STE 210
SAINT LOUIS MO
63122-6056
US

IV. Provider business mailing address

816 S KIRKWOOD RD STE 210
SAINT LOUIS MO
63122-6056
US

V. Phone/Fax

Practice location:
  • Phone: 314-645-4500
  • Fax: 314-645-5907
Mailing address:
  • Phone: 314-645-4500
  • Fax: 314-645-5907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number100200
License Number StateMO

VIII. Authorized Official

Name: LUCIANN LISI HRUZA
Title or Position: PRESIDENT
Credential: MD
Phone: 314-645-4500