Provider Demographics
NPI:1881615011
Name:DELAWARE DERMATOLOGICAL MEDICINE, INC.
Entity type:Organization
Organization Name:DELAWARE DERMATOLOGICAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUS. MGR
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-888-1577
Mailing Address - Street 1:14 ALDERS LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19807-3050
Mailing Address - Country:US
Mailing Address - Phone:302-888-1577
Mailing Address - Fax:
Practice Address - Street 1:14 ALDERS LN
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19807-3050
Practice Address - Country:US
Practice Address - Phone:302-888-1577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEE98195Medicare UPIN
DE52872BMedicare ID - Type Unspecified