Provider Demographics
NPI:1164458741
Name:LAYTON AVENUE DERMATOLOGY ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:LAYTON AVENUE DERMATOLOGY ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:ETHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-281-0712
Mailing Address - Street 1:2923 W LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2626
Mailing Address - Country:US
Mailing Address - Phone:414-281-0712
Mailing Address - Fax:414-281-3466
Practice Address - Street 1:2923 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2626
Practice Address - Country:US
Practice Address - Phone:414-281-0712
Practice Address - Fax:414-281-3466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32838600Medicaid
WI32838600Medicaid
WI73055Medicare ID - Type Unspecified