Provider Demographics
NPI:1104027556
Name:IMAGE DERMATOLOGY PC
Entity Type:Organization
Organization Name:IMAGE DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DOWNIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-509-6900
Mailing Address - Street 1:51 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3439
Mailing Address - Country:US
Mailing Address - Phone:973-509-6900
Mailing Address - Fax:973-509-6939
Practice Address - Street 1:51 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3439
Practice Address - Country:US
Practice Address - Phone:973-509-6900
Practice Address - Fax:973-509-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65931174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG51843Medicare UPIN
NJ951568Medicare PIN