Provider Demographics
NPI:1083188221
Name:INNOVATIVE DERMATOLOGY ALLIANCE CA
Entity Type:Organization
Organization Name:INNOVATIVE DERMATOLOGY ALLIANCE CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:U
Authorized Official - Last Name:REX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-994-4533
Mailing Address - Street 1:1027 N DEMAREE ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4117
Mailing Address - Country:US
Mailing Address - Phone:559-733-5050
Mailing Address - Fax:
Practice Address - Street 1:1027 N DEMAREE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4117
Practice Address - Country:US
Practice Address - Phone:559-733-5050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-21
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty