Provider Demographics
NPI:1144278441
Name:VALLEY DERMATOLOGY, PS, INC
Entity type:Organization
Organization Name:VALLEY DERMATOLOGY, PS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAYCOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:360-582-0808
Mailing Address - Street 1:565 EUREKA WAY
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-5074
Mailing Address - Country:US
Mailing Address - Phone:360-582-0808
Mailing Address - Fax:360-683-5678
Practice Address - Street 1:565 EUREKA WAY
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-5074
Practice Address - Country:US
Practice Address - Phone:360-582-0808
Practice Address - Fax:360-683-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035129207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7111479Medicaid
WAGAB26826Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
WA7111479Medicaid
WAP78823Medicare UPIN