Provider Demographics
NPI:1356343883
Name:DERMATOLOGY CENTER OF STAMFORD, LLC
Entity type:Organization
Organization Name:DERMATOLOGY CENTER OF STAMFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUZAN-CLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-325-3576
Mailing Address - Street 1:1290 SUMMER ST
Mailing Address - Street 2:SUITE 3600
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5360
Mailing Address - Country:US
Mailing Address - Phone:203-325-3576
Mailing Address - Fax:203-325-4280
Practice Address - Street 1:1290 SUMMER ST
Practice Address - Street 2:SUITE 3600
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5360
Practice Address - Country:US
Practice Address - Phone:203-325-3576
Practice Address - Fax:203-325-4280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCF8653OtherRAILROAD MEDICARE
CTCF8653OtherRAILROAD MEDICARE