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General NPI Number Information
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NPI Number | 1336253095
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Entity Type | Organization
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Legal Business Name | CLAYTON DERMATOLOGY LLC
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 03/15/2018
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Provider Practice Location Address
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Address Line | 816 S KIRKWOOD RD STE 210
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City | SAINT LOUIS
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State | MO
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Zip | 63122-6056
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Country | US
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Telephone | 314-645-4500
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Fax | 314-645-5907
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Provider Business Mailing Address
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Address Line | 816 S KIRKWOOD RD STE 210
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City | SAINT LOUIS
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State | MO
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Zip | 63122-6056
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Country | US
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Telephone | 314-645-4500
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Fax | 314-645-5907
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Authorized Official
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Title or Position | PRESIDENT
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Name | LUCIANN LISI HRUZA
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Credential | MD
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Telephone | 314-645-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 100200
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License Number State | MO
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