Provider Demographics
NPI:1174692610
Name:DERMATOLOGY ASSOCIATES OF KENTUCKY PSC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF KENTUCKY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-263-4444
Mailing Address - Street 1:250 FOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1888
Mailing Address - Country:US
Mailing Address - Phone:859-263-4444
Mailing Address - Fax:859-543-8867
Practice Address - Street 1:250 FOUNTAIN CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1888
Practice Address - Country:US
Practice Address - Phone:859-263-4444
Practice Address - Fax:859-543-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100120610Medicaid
KY65900391Medicaid
KY7100120610Medicaid
KYCL8904Medicare PIN