Provider Demographics
NPI:1497968945
Name:DERMATOLOGY ASSOCIATES LTD
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIVEK
Authorized Official - Middle Name:
Authorized Official - Last Name:IYENGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-444-8300
Mailing Address - Street 1:18425 W CREEK DR
Mailing Address - Street 2:STE F
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6767
Mailing Address - Country:US
Mailing Address - Phone:708-444-8300
Mailing Address - Fax:708-444-8301
Practice Address - Street 1:18425 W CREEK DR
Practice Address - Street 2:STE F
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6767
Practice Address - Country:US
Practice Address - Phone:708-444-8300
Practice Address - Fax:708-444-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618383174400000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210782Medicare PIN