Provider Demographics
NPI:1154493369
Name:DERMATOLOGY AND LASER GROUP OF IRVINE, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DERMATOLOGY AND LASER GROUP OF IRVINE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GLOBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-753-1001
Mailing Address - Street 1:16300 SAND CANYON AVE
Mailing Address - Street 2:612
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3711
Mailing Address - Country:US
Mailing Address - Phone:949-753-1001
Mailing Address - Fax:949-753-1115
Practice Address - Street 1:16300 SAND CANYON AVE
Practice Address - Street 2:612
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3711
Practice Address - Country:US
Practice Address - Phone:949-753-1001
Practice Address - Fax:949-753-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABS373OtherMEDICARE GROUP PTAN