Healthcare Provider Details

I. General information

NPI: 1396906988
Provider Name (Legal Business Name): CLOVIS DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 PARKLAND DR
CLOVIS NM
88101-4431
US

IV. Provider business mailing address

818 PARKLAND DR
CLOVIS NM
88101-4431
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-8890
  • Fax:
Mailing address:
  • Phone: 575-762-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA101294
License Number StateNM

VIII. Authorized Official

Name: DR. DONALD J BROWN
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 575-762-8890