Provider Demographics
NPI:1043211436
Name:DERMATOLOGICAL ASSOCIATES PC
Entity type:Organization
Organization Name:DERMATOLOGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-875-2080
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 LINCOLN WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:WHITE OAK
Practice Address - State:PA
Practice Address - Zip Code:15131
Practice Address - Country:US
Practice Address - Phone:412-678-8806
Practice Address - Fax:412-678-3780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006337010001Medicaid
PA959595OtherHIGHMARK
PA000823Medicare PIN