Provider Demographics
NPI:1497755797
Name:DERMATOLOGY & ALLERGY SPECIALISTS
Entity Type:Organization
Organization Name:DERMATOLOGY & ALLERGY SPECIALISTS
Other - Org Name:DERMATOLOGY & ALLERGY SPECIALISTS OF OLYMPIA
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-413-8297
Mailing Address - Street 1:304 W BAY DR NW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4953
Mailing Address - Country:US
Mailing Address - Phone:360-413-8760
Mailing Address - Fax:360-413-8839
Practice Address - Street 1:304 W BAY DR NW
Practice Address - Street 2:SUITE 301
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4958
Practice Address - Country:US
Practice Address - Phone:360-413-8760
Practice Address - Fax:360-413-8839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB20350OtherMEDICARE
WA7105927Medicaid
WAAB20350Medicare ID - Type Unspecified
WAGAB20350Medicare PIN