Provider Demographics
NPI:1144410945
Name:DERMATOLOGY SPECIALISTS, INC
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-757-7546
Mailing Address - Street 1:3629 VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056
Mailing Address - Country:US
Mailing Address - Phone:760-757-7546
Mailing Address - Fax:760-828-9138
Practice Address - Street 1:25495 MEDICAL CENTER DRIVE
Practice Address - Street 2:#200
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-304-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0029464Medicaid
CT1881631711OtherGROUP NPI
ZZZ005302Medicare PIN
CAGR0029464Medicaid