Provider Demographics
NPI:1235335902
Name:MID VALLEY DERMATOLOGY
Entity Type:Organization
Organization Name:MID VALLEY DERMATOLOGY
Other - Org Name:ALLAN S WIRTZER MD
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-907-7546
Mailing Address - Street 1:4836 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2101
Mailing Address - Country:US
Mailing Address - Phone:818-907-7546
Mailing Address - Fax:818-907-9506
Practice Address - Street 1:4836 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2101
Practice Address - Country:US
Practice Address - Phone:818-907-7546
Practice Address - Fax:818-907-9506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21007207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41138OtherALLAN S. WIRTZER, MD, MEDICAL DIRECTOR UPIN#
CAG21007OtherALLAN S. WIRTZER, MD, MEDICAL DIRECTOR ,CA LIC#
CA1326003161OtherALLAN S. WIRTZER, MD, MEDICAL DIRECTOR NPI#
CAG21007OtherALLAN S. WIRTZER, MD, MEDICAL DIRECTOR ,CA LIC#