Provider Demographics
NPI:1023068087
Name:ADVANCED DERMCARE PC
Entity type:Organization
Organization Name:ADVANCED DERMCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-731-2207
Mailing Address - Street 1:25 TAMARACK AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-4829
Mailing Address - Country:US
Mailing Address - Phone:203-797-8990
Mailing Address - Fax:203-748-7861
Practice Address - Street 1:25 TAMARACK AVE
Practice Address - Street 2:ADVANCED DERM CARE PC
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811
Practice Address - Country:US
Practice Address - Phone:203-797-8990
Practice Address - Fax:203-748-7861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004395390Medicaid