Healthcare Provider Details

I. General information

NPI: 1003657198
Provider Name (Legal Business Name): CALYX DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 ENCINO PL NE
ALBUQUERQUE NM
87102-2602
US

IV. Provider business mailing address

5863 MAFRAQ AVE NW
ALBUQUERQUE NM
87114-6071
US

V. Phone/Fax

Practice location:
  • Phone: 240-367-2980
  • Fax:
Mailing address:
  • Phone: 240-367-2980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CATHERINE TCHANQUE-FOSSUO
Title or Position: DERMATOLOGIST/MOHS SURGEON
Credential: MD, MS, FAAD
Phone: 240-367-2980