=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992343198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKIN WIN DERMATOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2019
-----------------------------------------------------
Last Update Date | 07/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1213 15TH AVE W STE 102
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-545-8637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 NIAGARA ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80230-6711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DANIEL HOFFMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-545-8637
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------