Provider Demographics
NPI:1154496248
Name:REDWOOD EMPIRE DERMATOLOGY INC
Entity Type:Organization
Organization Name:REDWOOD EMPIRE DERMATOLOGY INC
Other - Org Name:DERMATOLOGY ASSOCIATES OF SONOMA COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:WESTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:707-579-4239
Mailing Address - Street 1:990 SONOMA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4813
Mailing Address - Country:US
Mailing Address - Phone:707-579-4239
Mailing Address - Fax:707-579-0459
Practice Address - Street 1:990 SONOMA AVE STE 2
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4813
Practice Address - Country:US
Practice Address - Phone:707-579-4239
Practice Address - Fax:707-579-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27126ZMedicare ID - Type UnspecifiedGROUP NUMBER