Provider Demographics
NPI:1538875786
Name:LP DERM LLC
Entity type:Organization
Organization Name:LP DERM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-554-8442
Mailing Address - Street 1:517 W 100 N STE 103
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9824
Mailing Address - Country:US
Mailing Address - Phone:435-554-8442
Mailing Address - Fax:
Practice Address - Street 1:517 W 100 N STE 103
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9824
Practice Address - Country:US
Practice Address - Phone:435-554-8442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LP DERM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty