Provider Demographics
NPI:1689413445
Name:LIGHTHOUSE DERMATOLOGY AND SKIN CANCER SPECIALISTS
Entity type:Organization
Organization Name:LIGHTHOUSE DERMATOLOGY AND SKIN CANCER SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ESCOBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-381-8775
Mailing Address - Street 1:6363 29 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2401
Mailing Address - Country:US
Mailing Address - Phone:586-381-8775
Mailing Address - Fax:
Practice Address - Street 1:20 W CLARKSTON RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2972
Practice Address - Country:US
Practice Address - Phone:248-726-7646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-22
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery