Provider Demographics
NPI:1578694238
Name:DERMATOLOGY CENTER OF CANYON COUNTY
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF CANYON COUNTY
Other - Org Name:DERMATOLOGY & LASER CENTER OF CANYON COUNTY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-467-3006
Mailing Address - Street 1:318 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3765
Mailing Address - Country:US
Mailing Address - Phone:208-467-3006
Mailing Address - Fax:208-467-1155
Practice Address - Street 1:318 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3765
Practice Address - Country:US
Practice Address - Phone:208-467-3006
Practice Address - Fax:208-467-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7519207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376908Medicare ID - Type Unspecified