Provider Demographics
NPI:1679852396
Name:NW DERMATOLOGY AND RESEARCH CENTER, LLC
Entity Type:Organization
Organization Name:NW DERMATOLOGY AND RESEARCH CENTER, LLC
Other - Org Name:NW DERMATOLOGY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NISHA
Authorized Official - Middle Name:SHAH
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-223-1933
Mailing Address - Street 1:2525 NW LOVEJOY ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2865
Mailing Address - Country:US
Mailing Address - Phone:503-223-1933
Mailing Address - Fax:
Practice Address - Street 1:2525 NW LOVEJOY ST STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2865
Practice Address - Country:US
Practice Address - Phone:503-223-1933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty