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General NPI Number Information
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NPI Number | 1609170992
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY ASSOCIATES OF ITHACA, LLC
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Dates
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Enumeration Date | 01/01/2011
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Last Update Date | 10/09/2024
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Provider Practice Location Address
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Address Line | 1051 CRAFT RD
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City | ITHACA
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State | NY
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Zip | 14850-1016
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Country | US
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Telephone | 607-257-1107
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Fax | 607-257-0369
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Provider Business Mailing Address
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Address Line | 1051 CRAFT RD
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City | ITHACA
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State | NY
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Zip | 14850-1016
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Country | US
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Telephone | 607-257-1107
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Fax | 607-257-0369
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KATIE TERRAZAS
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Credential |
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Telephone | 607-257-1107
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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 | 250861
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License Number State | NY
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