Healthcare Provider Details

I. General information

NPI: 1659361418
Provider Name (Legal Business Name): DERMATOLOGY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S TELSHOR BLVD BUILDING 15 SUITE 200
LAS CRUCES NM
88011-9148
US

IV. Provider business mailing address

2525 S TELSHOR BLVD BUILDING 15 SUITE 200
LAS CRUCES NM
88011-9148
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-3636
  • Fax: 505-522-0722
Mailing address:
  • Phone: 505-522-3636
  • Fax: 505-522-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number95-143
License Number StateNM

VIII. Authorized Official

Name: DR. ROBERT J SEGAL
Title or Position: PRESIDENT
Credential: MD
Phone: 505-522-3636