Provider Demographics
NPI:1225127244
Name:DEERFIELD DERMATOLOGY ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:DEERFIELD DERMATOLOGY ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTFREDSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-480-0004
Mailing Address - Street 1:707 LAKE COOK RD
Mailing Address - Street 2:SUITE #280
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4909
Mailing Address - Country:US
Mailing Address - Phone:847-480-0004
Mailing Address - Fax:847-480-8707
Practice Address - Street 1:707 LAKE COOK RD
Practice Address - Street 2:SUITE #280
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4909
Practice Address - Country:US
Practice Address - Phone:847-480-0004
Practice Address - Fax:847-480-8707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-618435207N00000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty