Provider Demographics
NPI:1780937045
Name:DERMATOLOGY & LASER SURGERY CTR
Entity type:Organization
Organization Name:DERMATOLOGY & LASER SURGERY CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-461-5655
Mailing Address - Street 1:2125 CENTER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5859
Mailing Address - Country:US
Mailing Address - Phone:201-461-5655
Mailing Address - Fax:201-461-1181
Practice Address - Street 1:2125 CENTER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5859
Practice Address - Country:US
Practice Address - Phone:201-461-5655
Practice Address - Fax:201-461-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ65361207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty