Provider Demographics
NPI:1629260435
Name:LITCHFIELD HILLS DERMATOLOGY, PC
Entity Type:Organization
Organization Name:LITCHFIELD HILLS DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:DIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-494-5777
Mailing Address - Street 1:409 BANTAM RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3200
Mailing Address - Country:US
Mailing Address - Phone:860-361-9660
Mailing Address - Fax:860-361-9659
Practice Address - Street 1:409 BANTAM RD STE 2A
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3200
Practice Address - Country:US
Practice Address - Phone:860-361-9660
Practice Address - Fax:860-361-9659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044520207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF32061Medicare UPIN