Provider Demographics
NPI:1295819290
Name:CANTON DERMATOLOGY CLINIC, INC
Entity type:Organization
Organization Name:CANTON DERMATOLOGY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAFAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUPAIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-821-2888
Mailing Address - Street 1:95 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-4006
Mailing Address - Country:US
Mailing Address - Phone:781-821-2888
Mailing Address - Fax:781-821-8684
Practice Address - Street 1:95 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-4006
Practice Address - Country:US
Practice Address - Phone:781-821-2888
Practice Address - Fax:781-821-8684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21105Medicare PIN
MA03-00257OtherUNITED HEALTHCARE
MA6192041Medicaid
MA665814OtherTUFTS HEALTHPLAN
MA=========-00OtherNEIGHBORHOOD HEALTH
MAM17812OtherBC BS MA
MA4069OtherHARVARD PILGRIM
MA000000032938OtherBMC HEALTHNET