Provider Demographics
NPI:1982105425
Name:MOD DERMATOLOGY PC
Entity Type:Organization
Organization Name:MOD DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATERA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:402-505-8777
Mailing Address - Street 1:16910 FRANCES ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2398
Mailing Address - Country:US
Mailing Address - Phone:402-505-8777
Mailing Address - Fax:402-933-7767
Practice Address - Street 1:16910 FRANCES ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2398
Practice Address - Country:US
Practice Address - Phone:402-505-8777
Practice Address - Fax:402-933-7767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 207N00000X, 363A00000X
NE28493207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty