Provider Demographics
NPI:1235264284
Name:DERMATOLOGY & SKIN CANCER CENTER OF NM PC
Entity Type:Organization
Organization Name:DERMATOLOGY & SKIN CANCER CENTER OF NM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CANGIOLOSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-243-7546
Mailing Address - Street 1:5120 MASTHEAD ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4366
Mailing Address - Country:US
Mailing Address - Phone:505-243-7546
Mailing Address - Fax:505-243-7547
Practice Address - Street 1:5120 MASTHEAD ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4366
Practice Address - Country:US
Practice Address - Phone:505-243-7546
Practice Address - Fax:505-243-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207ND0101X, 207ND0900X
NM2827483302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH01529Medicare UPIN
NMG75017Medicare UPIN