Provider Demographics
NPI:1326162538
Name:CAYCE DERMATOLOGY CENTER AND MEDICAL SPA, PC
Entity Type:Organization
Organization Name:CAYCE DERMATOLOGY CENTER AND MEDICAL SPA, PC
Other - Org Name:JOHN DESPAIN MD AND KIMBERLY CAYCE MD DERMATOLOGY, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAYCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-234-1000
Mailing Address - Street 1:2011 CORONA RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2548
Mailing Address - Country:US
Mailing Address - Phone:573-234-1000
Mailing Address - Fax:573-234-1771
Practice Address - Street 1:2011 CORONA RD
Practice Address - Street 2:SUITE 207
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5922
Practice Address - Country:US
Practice Address - Phone:573-234-1000
Practice Address - Fax:573-234-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
MOR8E64174400000X
MO094877363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE24179Medicare UPIN
MO001013494Medicare ID - Type UnspecifiedDR JOHN DESPAIN INDIVIDUA
MO000013494Medicare PIN