Provider Demographics
NPI:1477649887
Name:OAKLAND DERMATOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:OAKLAND DERMATOLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NELDAGAE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-647-5015
Mailing Address - Street 1:36700 WOODWARD AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0926
Mailing Address - Country:US
Mailing Address - Phone:248-647-5750
Mailing Address - Fax:248-647-6008
Practice Address - Street 1:36700 WOODWARD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0926
Practice Address - Country:US
Practice Address - Phone:248-647-5750
Practice Address - Fax:248-647-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301022545207N00000X, 332900000X
MI4301032103208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2368466OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0N95790Medicare PIN