Provider Demographics
NPI:1962682195
Name:MEDICAL ARTS DERMATOLOGY PC
Entity Type:Organization
Organization Name:MEDICAL ARTS DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-299-4414
Mailing Address - Street 1:801 ENCINO PL NE
Mailing Address - Street 2:STE E6
Mailing Address - City:ALBUQ
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2645
Mailing Address - Country:US
Mailing Address - Phone:505-299-4414
Mailing Address - Fax:505-299-4513
Practice Address - Street 1:801 ENCINO PL NE
Practice Address - Street 2:STE E6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2645
Practice Address - Country:US
Practice Address - Phone:505-299-4414
Practice Address - Fax:505-299-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6534174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM900521020Medicare Oscar/Certification