Provider Demographics
NPI:1003209248
Name:AZEAL DERMATOLOGY INSTITUTE, LLC
Entity Type:Organization
Organization Name:AZEAL DERMATOLOGY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PILKINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-530-9325
Mailing Address - Street 1:PO BOX 7446
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0446
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-667-0847
Practice Address - Street 1:5365 SPINE RD
Practice Address - Street 2:SUITE C
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3324
Practice Address - Country:US
Practice Address - Phone:303-530-9325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77885376Medicaid
CO414110Medicare PIN