Provider Demographics
NPI:1922605906
Name:DELUXE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:DELUXE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:ARDIE
Authorized Official - Last Name:DILWORTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:314-781-0794
Mailing Address - Street 1:1034 S BRENTWOOD BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1210
Mailing Address - Country:US
Mailing Address - Phone:314-781-0794
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD STE 1000
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1210
Practice Address - Country:US
Practice Address - Phone:314-781-0794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020010839OtherMISSOURI BOARD OF REGISTRATION FOR THE HEALING ARTS