Basic Information
| Provider Information | |||||||||
| NPI: | 1376645143 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY & LASER CENTER AT HARVARD PARK, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DERMATOLOGY & LASER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 E HARVARD AVE | ||||||||
| Address2: | STE 440 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802107009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037442704 | ||||||||
| FaxNumber: | 3037443244 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 E HARVARD AVE | ||||||||
| Address2: | STE 440 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802107009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037442704 | ||||||||
| FaxNumber: | 3037443244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 05/17/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EUBANKS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3037442704 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | CH4005 | 01 | CO | RR MEDICARE | OTHER | 87557011 | 05 | CO | MEDICAID | DE635330 | 01 | CO | BCBS | OTHER |