Provider Demographics
NPI:1477559128
Name:COMMONWEALTH DERMATOLOGY PSC
Entity Type:Organization
Organization Name:COMMONWEALTH DERMATOLOGY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SEDORIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-276-0191
Mailing Address - Street 1:2351 HUGUENARD DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3022
Mailing Address - Country:US
Mailing Address - Phone:859-276-0191
Mailing Address - Fax:859-277-0466
Practice Address - Street 1:2351 HUGUENARD DR
Practice Address - Street 2:STE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3022
Practice Address - Country:US
Practice Address - Phone:859-276-0191
Practice Address - Fax:859-277-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty