Provider Demographics
NPI:1699021386
Name:MOUNTAINTOP DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:MOUNTAINTOP DERMATOLOGY, PLLC
Other - Org Name:FRANK M. SAMARIN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-265-0100
Mailing Address - Street 1:2465 RESEARCH PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1089
Mailing Address - Country:US
Mailing Address - Phone:719-265-0100
Mailing Address - Fax:
Practice Address - Street 1:2465 RESEARCH PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1089
Practice Address - Country:US
Practice Address - Phone:719-265-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06220576207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1699021386Medicaid
COA108836OtherPTAN
CO06220576Medicaid
CO73232831Medicaid
COA108837OtherPTAN
CO1629037395Medicaid