Provider Demographics
NPI:1104028968
Name:DERMATOLOGY SPECIALISTS OF WELLESLEY PC
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF WELLESLEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:F
Authorized Official - Last Name:SPITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-237-3412
Mailing Address - Street 1:332 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-6219
Mailing Address - Country:US
Mailing Address - Phone:781-237-3412
Mailing Address - Fax:781-235-6786
Practice Address - Street 1:332 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6219
Practice Address - Country:US
Practice Address - Phone:781-237-3412
Practice Address - Fax:781-235-6786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52765207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3092291Medicaid
MAM21362Medicare PIN