MEDICARE: UPTOWN DERMATOLOGY & SKIN SPA, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1205868619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPTOWN DERMATOLOGY & SKIN SPA, P.A.

Provider Business Mailing Address
First Line	:	1221 W LAKE ST
Second Line	:	SUITE 208
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3397
Country	:	US
Telephone Number	:	612-455-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 W LAKE ST
Second Line	:	SUITE 208
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3397
Country	:	US
Telephone Number	:	612-455-3200
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAIME DAVIS
Credential	:	M.D.
Telephone Number	:	612-455-3200

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	08/22/2020

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