Provider Demographics
NPI:1770828626
Name:DERMATOLOGY AND MOHS SURGERY INSTITUTE, LTD.
Entity Type:Organization
Organization Name:DERMATOLOGY AND MOHS SURGERY INSTITUTE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-678-9596
Mailing Address - Street 1:3024 E EMPIRE ST
Mailing Address - Street 2:2ND FLOOR, SUITE F
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-5402
Mailing Address - Country:US
Mailing Address - Phone:309-678-9596
Mailing Address - Fax:
Practice Address - Street 1:3024 E EMPIRE ST
Practice Address - Street 2:2ND FLOOR, SUITE F
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-5402
Practice Address - Country:US
Practice Address - Phone:309-678-9596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.129240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty