Provider Demographics
NPI:1346306289
Name:DERMATOLOGY ASSOCIATES OF SOUTHEASTERN CONNECTICUT, P.C.
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF SOUTHEASTERN CONNECTICUT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:WILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-442-1346
Mailing Address - Street 1:425 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4642
Mailing Address - Country:US
Mailing Address - Phone:860-442-1346
Mailing Address - Fax:860-444-6208
Practice Address - Street 1:425 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4642
Practice Address - Country:US
Practice Address - Phone:860-442-1346
Practice Address - Fax:860-444-6208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4090841Medicaid
CTC02407Medicare ID - Type Unspecified