Healthcare Provider Details

I. General information

NPI: 1982791109
Provider Name (Legal Business Name): ALBUQUERQUE CENTER FOR DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2006
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 CONSTITUTION PL NE SUITE 310
ALBUQUERQUE NM
87110-7643
US

IV. Provider business mailing address

8100 CONSTITUTION PL NE SUITE 310
ALBUQUERQUE NM
87110-7643
US

V. Phone/Fax

Practice location:
  • Phone: 505-293-5333
  • Fax: 505-293-5334
Mailing address:
  • Phone: 505-293-5333
  • Fax: 505-293-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number67-57
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number67-57
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number67-57
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number67-57
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number67-57
License Number StateNM

VIII. Authorized Official

Name: DR. VINCENT A MUSCARELLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-293-5333