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General NPI Number Information
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NPI Number | 1427270727
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Entity Type | Organization
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Legal Business Name | UPPER WEST SIDE DERMATOLOGY, P.C.
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 12/12/2019
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Provider Practice Location Address
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Address Line | 277 W END AVE APT 1B
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City | NEW YORK
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State | NY
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Zip | 10023-2605
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Country | US
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Telephone | 212-769-0069
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Fax |
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Provider Business Mailing Address
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Address Line | 277 W END AVE APT 1B
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City | NEW YORK
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State | NY
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Zip | 10023-2605
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Country | US
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Telephone | 212-769-0069
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Fax |
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Authorized Official
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Title or Position | SOLE OWNER
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Name | DR. LISA TRAVIS
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Credential | M.D.
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Telephone | 212-769-0069
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 238877
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License Number State | NY
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