Provider Demographics
NPI:1518100312
Name:CRESCENT CITY DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:CRESCENT CITY DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:614-937-0319
Mailing Address - Street 1:1107 S PETERS ST
Mailing Address - Street 2:UNIT 404
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70130-1759
Mailing Address - Country:US
Mailing Address - Phone:614-937-0319
Mailing Address - Fax:
Practice Address - Street 1:120 MEADOWCREST ST
Practice Address - Street 2:SUITE 460
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5255
Practice Address - Country:US
Practice Address - Phone:614-937-0319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200999207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1216887Medicaid
1356531677OtherNPI NUMBER