Healthcare Provider Details

I. General information

NPI: 1316324841
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF SANTA FE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 OLD PECOS TRL SUITE J
SANTA FE NM
87505-4760
US

IV. Provider business mailing address

902 CLINT MOORE RD SUITE 226
BOCA RATON FL
33487-2800
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-5120
  • Fax:
Mailing address:
  • Phone: 561-314-2000
  • Fax: 561-431-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: GERRY CHRISTOPHER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 561-314-2000