MEDICARE: ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA

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	207NS0135X	Procedural Dermatology Physician	2000-166	NM
2	207NS0135X	Procedural Dermatology Physician	2002-0450	NM
3	207NS0135X	Procedural Dermatology Physician	R46867NM	NM
4	207NS0135X	Procedural Dermatology Physician	MD2005-0405	NM
5	207N00000X	Dermatology Physician	2002-0450	NM
6	207N00000X	Dermatology Physician	R46867NM	NM
7	207N00000X	Dermatology Physician	MD2005-0405	NM
8	207ND0101X	MOHS-Micrographic Surgery Physician	2000-166	NM
9	207N00000X	Dermatology Physician	2000-166	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821045329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA

Provider Business Mailing Address
First Line	:	4610 JEFFERSON LN NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-2117
Country	:	US
Telephone Number	:	505-872-4700
Fax Number	:	505-872-4709

Provider Business Practice Location Address
First Line	:	4610 JEFFERSON LN NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-2117
Country	:	US
Telephone Number	:	505-872-4700
Fax Number	:	505-872-4709

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MS. ESTELLE B MILLER
Credential	:
Telephone Number	:	505-872-4700

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	03/06/2008

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