Provider Demographics
NPI:1275622664
Name:NORTH BAY DERMATOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:NORTH BAY DERMATOLOGY ASSOCIATES
Other - Org Name:GLENN A. KOBY, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:
Authorized Official - Last Name:CENTURION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-763-6816
Mailing Address - Street 1:106 LYNCH CREEK WAY
Mailing Address - Street 2:SUITE #8
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2356
Mailing Address - Country:US
Mailing Address - Phone:707-763-6816
Mailing Address - Fax:707-763-1730
Practice Address - Street 1:106 LYNCH CREEK WAY
Practice Address - Street 2:SUITE #8
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2356
Practice Address - Country:US
Practice Address - Phone:707-763-6816
Practice Address - Fax:707-763-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAJ5792OtherRAILTOAD MEDICARE
CAZZZ34981ZMedicare ID - Type Unspecified