Provider Demographics
NPI:1053561928
Name:EAGLE CREEK DERMATOLOGY
Entity type:Organization
Organization Name:EAGLE CREEK DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INGRIDA
Authorized Official - Middle Name:IVETA
Authorized Official - Last Name:OZOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-329-7050
Mailing Address - Street 1:6820 PARKDALE PL
Mailing Address - Street 2:SUITE 211
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-6600
Mailing Address - Country:US
Mailing Address - Phone:317-329-7050
Mailing Address - Fax:317-328-6809
Practice Address - Street 1:6820 PARKDALE PL
Practice Address - Street 2:SUITE 211
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6600
Practice Address - Country:US
Practice Address - Phone:317-329-7050
Practice Address - Fax:317-328-6809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027554207N00000X
IN01024873207NI0002X
IN01057248207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty