Provider Demographics
NPI:1932215142
Name:DERMATOLOGY CENTER OF RIDGEWOOD, LLC
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF RIDGEWOOD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:KOPELOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-444-5667
Mailing Address - Street 1:1 SEARS DR
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3515
Mailing Address - Country:US
Mailing Address - Phone:201-265-2994
Mailing Address - Fax:201-265-2294
Practice Address - Street 1:1 SEARS DR
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3515
Practice Address - Country:US
Practice Address - Phone:201-265-2994
Practice Address - Fax:201-265-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05983500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF61763Medicare UPIN