Provider Demographics
NPI:1043344476
Name:DERMATOLOGY OF SANTA FE PC
Entity Type:Organization
Organization Name:DERMATOLOGY OF SANTA FE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:JESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-986-9688
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:SUITE N9B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2143
Mailing Address - Country:US
Mailing Address - Phone:505-986-9688
Mailing Address - Fax:505-986-9090
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:SUITE N-9B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-986-9688
Practice Address - Fax:505-986-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0502207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1548260995OtherNPI
1548260995OtherNPI