Provider Demographics
NPI:1912262338
Name:DERMATOLOGY ELECTRONIC CONSULTANTS, PROFESSIONAL LLC
Entity Type:Organization
Organization Name:DERMATOLOGY ELECTRONIC CONSULTANTS, PROFESSIONAL LLC
Other - Org Name:DERMECONSULT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ALKOUSAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-400-7260
Mailing Address - Street 1:240 ELIZABETH ST
Mailing Address - Street 2:SUITE H-1, #15
Mailing Address - City:ELIZABETH
Mailing Address - State:CO
Mailing Address - Zip Code:80107-7537
Mailing Address - Country:US
Mailing Address - Phone:319-400-7260
Mailing Address - Fax:
Practice Address - Street 1:240 ELIZABETH ST
Practice Address - Street 2:SUITE A-1, #15
Practice Address - City:ELIZABETH
Practice Address - State:CO
Practice Address - Zip Code:80107-7537
Practice Address - Country:US
Practice Address - Phone:319-400-7260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty