Provider Demographics
NPI:1639483704
Name:DERMATOLOGY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:FURNAE CAMPBELL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-257-1484
Mailing Address - Street 1:931 E 86TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1860
Mailing Address - Country:US
Mailing Address - Phone:317-257-1484
Mailing Address - Fax:317-257-1488
Practice Address - Street 1:931 E 86TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1860
Practice Address - Country:US
Practice Address - Phone:317-257-1484
Practice Address - Fax:317-257-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-01
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049424174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000132230Medicare NSC
IN132230Medicare PIN