ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA

Provider Demographics

• NPI: 1821045329
• Name: ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA
• Entity Type: Organization
• Organization Name: ALBUQUERQUE DERMATOLOGY ASSOCIATES, PA
• Authorized Official - Title/Position: PRACTICE MANAGER
• Authorized Official - Prefix: MS
• Authorized Official - First Name: ESTELLE
• Authorized Official - Middle Name: B
• Authorized Official - Last Name: MILLER
• Authorized Official - Phone: 505-872-4700
• Mailing Address - Street 1: 4610 JEFFERSON LN NE
• Mailing Address - City: ALBUQUERQUE
• Mailing Address - State: NM
• Mailing Address - Zip Code: 87109-2117
• Mailing Address - Country: US
• Mailing Address - Phone: 505-872-4700
• Mailing Address - Fax: 505-872-4709
• Practice Address - Street 1: 4610 JEFFERSON LN NE
• Practice Address - City: ALBUQUERQUE
• Practice Address - State: NM
• Practice Address - Zip Code: 87109-2117
• Practice Address - Country: US
• Practice Address - Phone: 505-872-4700
• Practice Address - Fax: 505-872-4709
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-05-28
• Last Update Date: 2008-03-06

Provider Licenses

State	License ID	Taxonomies
NM	2002-0450	207N00000X, 207NS0135X
NM	R46867NM	207N00000X, 207NS0135X
NM	MD2005-0405	207N00000X, 207NS0135X
NM	2000-166	207N00000X, 207ND0101X, 207NS0135X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207N00000X	Allopathic & Osteopathic Physicians	Dermatology		Group - Multi-Specialty
No	207ND0101X	Allopathic & Osteopathic Physicians	Dermatology	MOHS-Micrographic Surgery	Group - Multi-Specialty
No	207NS0135X	Allopathic & Osteopathic Physicians	Dermatology	Procedural Dermatology	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NM	76659755	Medicaid
NM	F1418	Medicaid
NM	44792	Medicaid
NM	47235306	Medicaid
NM	93885865	Medicaid
NM	1821045329	Medicare UPIN
NM	44792	Medicaid
NM	93885865	Medicaid
NM	1558465153	Medicare UPIN
NM	F1418	Medicaid