Provider Demographics
NPI:1750487880
Name:DERMATOLOGY CLINIC INC A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:DERMATOLOGY CLINIC INC A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:LEHR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-951-4949
Mailing Address - Street 1:5701 N PORTLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-1670
Mailing Address - Country:US
Mailing Address - Phone:405-951-4949
Mailing Address - Fax:405-951-4005
Practice Address - Street 1:5701 N PORTLAND AVE STE 310
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-1670
Practice Address - Country:US
Practice Address - Phone:405-951-4949
Practice Address - Fax:405-951-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522502Medicare PIN