MEDICARE: DERMATOLOGY ASSOCIATES OF ITHACA, LLC

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	250861	NY

General Provider Information

NPI Number	:	1609170992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY ASSOCIATES OF ITHACA, LLC

Provider Business Mailing Address
First Line	:	1051 CRAFT RD
Second Line	:
City	:	ITHACA
State	:	NY
Zip	:	14850-1016
Country	:	US
Telephone Number	:	607-257-1107
Fax Number	:	607-257-0369

Provider Business Practice Location Address
First Line	:	1051 CRAFT RD
Second Line	:
City	:	ITHACA
State	:	NY
Zip	:	14850-1016
Country	:	US
Telephone Number	:	607-257-1107
Fax Number	:	607-257-0369

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KATIE TERRAZAS
Credential	:
Telephone Number	:	607-257-1107

Provider Enumeration Date	:	01/01/2011
Last Update Date	:	10/09/2024

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