Organization
DERMATOLOGY SPECIALISTS, PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
J. MARK JACKSON M.D. (PARTNER)
(502) 583-7546
Entity
Organization
Contact information
Practice address
501 S 2ND ST, FIRST FLOOR, LOUISVILLE, KY 40202-2862
(502) 583-7546
(502) 589-3429
Mailing address
501 S 2ND ST, FIRST FLOOR, LOUISVILLE, KY 40202-2862
(502) 583-7546
(502) 589-3429
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
—
—
207N00000X
Dermatology Physician
Primary
—
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1052384
PASSPORT
KY
05
—
200044790B
—
IN
01
—
2433273000
PASSPORT ADVANTAGE
KY
01
—
CA7485
RRR MEDICARE
—
Enumeration date
01/17/2007
Last updated
01/17/2014
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