Provider Demographics
NPI:1194838441
Name:GROSSMONT DERMATOLOGY MEDICAL CLINIC
Entity Type:Organization
Organization Name:GROSSMONT DERMATOLOGY MEDICAL CLINIC
Other - Org Name:COASTAL SKIN AND EYE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEL VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-462-1670
Mailing Address - Street 1:8860 CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3068
Mailing Address - Country:US
Mailing Address - Phone:619-462-1670
Mailing Address - Fax:619-462-3209
Practice Address - Street 1:8860 CENTER DR
Practice Address - Street 2:STE 300
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3068
Practice Address - Country:US
Practice Address - Phone:619-462-1670
Practice Address - Fax:619-462-3209
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL SKIN AND EYE INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A233400Medicaid
CA00G733400Medicaid
CAWA23340AMedicare PIN
A82787Medicare UPIN
CADK853ZMedicare PIN
CAA91044Medicare UPIN
CA00A233400Medicaid
CAWG73340BMedicare PIN
CAW3330Medicare PIN
CA00G733400Medicaid
CAWG27334AMedicare PIN
CAP99406Medicare UPIN
CA05D0567864Medicare Oscar/Certification