Provider Demographics
NPI:1114999018
Name:DERMATOLOGY AND ENDOCRINOLOGY LLC
Entity Type:Organization
Organization Name:DERMATOLOGY AND ENDOCRINOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:K
Authorized Official - Last Name:DERNOVSEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-564-4500
Mailing Address - Street 1:1925 E ORMAN AVE
Mailing Address - Street 2:STE 115
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-564-4500
Mailing Address - Fax:719-564-0304
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:STE 115
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3500
Practice Address - Country:US
Practice Address - Phone:719-564-4500
Practice Address - Fax:719-564-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26083207N00000X
CO26084207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96378352Medicaid
CO1114999018OtherRAILROAD MEDICARE
COC451128Medicare PIN