Provider Demographics
NPI:1215003579
Name:ADIRONDACK DERMATOLOGY PC
Entity Type:Organization
Organization Name:ADIRONDACK DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJORDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-563-7546
Mailing Address - Street 1:1753 ROUTE 3
Mailing Address - Street 2:ADIRONDACK DERMATOLOGY PC
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962
Mailing Address - Country:US
Mailing Address - Phone:518-563-7546
Mailing Address - Fax:518-562-5458
Practice Address - Street 1:1753 ROUTE 3
Practice Address - Street 2:ADIRONDACK DERMATOLOGY PC
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12962
Practice Address - Country:US
Practice Address - Phone:518-563-7546
Practice Address - Fax:518-562-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2016181207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G22393Medicare UPIN
55946AMedicare ID - Type Unspecified