Provider Demographics
NPI:1982791109
Name:ALBUQUERQUE CENTER FOR DERMATOLOGY, PA
Entity Type:Organization
Organization Name:ALBUQUERQUE CENTER FOR DERMATOLOGY, PA
Other - Org Name:ABQ CENTER FOR DERMATOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUSCARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-293-5333
Mailing Address - Street 1:8100 CONSTITUTION PL NE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7643
Mailing Address - Country:US
Mailing Address - Phone:505-293-5333
Mailing Address - Fax:505-293-5334
Practice Address - Street 1:8100 CONSTITUTION PL NE
Practice Address - Street 2:SUITE 310
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7643
Practice Address - Country:US
Practice Address - Phone:505-293-5333
Practice Address - Fax:505-293-5334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-08
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM67-57207N00000X, 207ND0101X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20107Medicaid
NMD35857Medicare UPIN
NM2126281Medicare PIN