Provider Demographics
NPI:1548409139
Name:SOUTHERN COLORADO DERMATOLOGY CLINIC PC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO DERMATOLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:NAKAMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-564-5544
Mailing Address - Street 1:900 INDIANA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3767
Mailing Address - Country:US
Mailing Address - Phone:719-564-5544
Mailing Address - Fax:
Practice Address - Street 1:900 INDIANA AVE STE C
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3767
Practice Address - Country:US
Practice Address - Phone:719-564-5544
Practice Address - Fax:719-564-2246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44146207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty