Provider Demographics
NPI:1518146323
Name:DERMATOLOGY CENTER OF OXFORD, P.C.
Entity type:Organization
Organization Name:DERMATOLOGY CENTER OF OXFORD, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:BONINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:248-390-0435
Mailing Address - Street 1:2227 ROCK VALLEY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:METAMORA
Mailing Address - State:MI
Mailing Address - Zip Code:48455-9333
Mailing Address - Country:US
Mailing Address - Phone:248-390-0435
Mailing Address - Fax:
Practice Address - Street 1:2227 ROCK VALLEY RD
Practice Address - Street 2:SUITE A
Practice Address - City:METAMORA
Practice Address - State:MI
Practice Address - Zip Code:48455-9333
Practice Address - Country:US
Practice Address - Phone:248-390-0435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010573207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG23913Medicare UPIN