Provider Demographics
NPI:1174653299
Name:WESTERN DERMATOLOGY CONSULTANTS PC
Entity Type:Organization
Organization Name:WESTERN DERMATOLOGY CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-855-5503
Mailing Address - Street 1:10151 MONTGOMERY NE BLDG. 1
Mailing Address - Street 2:STE. A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-855-5503
Mailing Address - Fax:505-855-5533
Practice Address - Street 1:10151 MONTGOMERY BLVD NE
Practice Address - Street 2:BLDG. 1 STE. A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3670
Practice Address - Country:US
Practice Address - Phone:505-855-5503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP6441Medicaid