Provider Demographics
NPI:1326176983
Name:ACCREDITED DERMATOLOGY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:ACCREDITED DERMATOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-355-3376
Mailing Address - Street 1:2322 E KIMBERLY RD
Mailing Address - Street 2:SUITE N100
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7205
Mailing Address - Country:US
Mailing Address - Phone:563-355-3376
Mailing Address - Fax:
Practice Address - Street 1:2322 E KIMBERLY RD
Practice Address - Street 2:SUITE N100
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7205
Practice Address - Country:US
Practice Address - Phone:563-355-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17538207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0090084Medicaid
IAA00999Medicare UPIN
IA0090084Medicaid