Provider Demographics
NPI:1013035138
Name:ADULT & PEDIATRIC DERMATOLOGY SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:ADULT & PEDIATRIC DERMATOLOGY SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-377-0639
Mailing Address - Street 1:160 HAWLEY LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5300
Mailing Address - Country:US
Mailing Address - Phone:203-377-0639
Mailing Address - Fax:203-386-9706
Practice Address - Street 1:160 HAWLEY LN
Practice Address - Street 2:SUITE 104
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-5300
Practice Address - Country:US
Practice Address - Phone:203-377-0639
Practice Address - Fax:203-386-9706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00309Medicare PIN