Provider Demographics
NPI:1710370648
Name:ADVANCED DERMATOLOGY OF COLORADO, PC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY OF COLORADO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR-PROVIDER SERVICES
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
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:
Practice Address - Street 1:1100 POUDRE RIVER DR UNIT A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3557
Practice Address - Country:US
Practice Address - Phone:970-484-6303
Practice Address - Fax:970-484-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty