Provider Demographics
NPI:1891392973
Name:COLORADO SPRINGS DERMATOLOGY CLINIC, P.C.
Entity Type:Organization
Organization Name:COLORADO SPRINGS DERMATOLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPARTMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-471-1763
Mailing Address - Street 1:170 S PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3129
Mailing Address - Country:US
Mailing Address - Phone:719-471-1763
Mailing Address - Fax:719-471-2498
Practice Address - Street 1:2060 BRIARGATE PKWY STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7660
Practice Address - Country:US
Practice Address - Phone:719-471-1763
Practice Address - Fax:719-471-2498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-02
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty