Provider Demographics
NPI:1568033066
Name:INTEGRATED DERMATOLOGY OF BOULDER CREEK, LLC
Entity Type:Organization
Organization Name:INTEGRATED DERMATOLOGY OF BOULDER CREEK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-314-2000
Mailing Address - Street 1:4700 EXCHANGE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4450
Mailing Address - Country:US
Mailing Address - Phone:561-431-2821
Mailing Address - Fax:
Practice Address - Street 1:400 S MCCASLIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-9701
Practice Address - Country:US
Practice Address - Phone:303-666-5261
Practice Address - Fax:303-604-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000168857Medicaid