Provider Demographics
NPI:1033241138
Name:SOUTH COAST DERMATOLOGY INSTITUTE, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOUTH COAST DERMATOLOGY INSTITUTE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:F
Authorized Official - Last Name:AFSAHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-508-0754
Mailing Address - Street 1:2552 WALNUT AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6935
Mailing Address - Country:US
Mailing Address - Phone:714-508-0754
Mailing Address - Fax:714-508-5754
Practice Address - Street 1:2552 WALNUT AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6935
Practice Address - Country:US
Practice Address - Phone:714-508-0754
Practice Address - Fax:714-508-5754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700888690OtherNPI TYPE I IND.DR. AFSAHI
CA1700888690OtherNPI TYPE I IND.DR. AFSAHI
CAY01054Medicare UPIN