Provider Demographics
NPI:1689860504
Name:DUBUQUE DERMATOLOGY P.C.
Entity type:Organization
Organization Name:DUBUQUE DERMATOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:SATO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-582-9306
Mailing Address - Street 1:2140 JFK RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-3883
Mailing Address - Country:US
Mailing Address - Phone:563-582-9306
Mailing Address - Fax:563-582-6879
Practice Address - Street 1:2140 JFK RD
Practice Address - Street 2:SUITE A
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-3883
Practice Address - Country:US
Practice Address - Phone:563-582-9306
Practice Address - Fax:563-582-6879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21029174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1148981Medicaid
IA1148981Medicaid