Provider Demographics
NPI:1346261617
Name:NORTHRIDGE DERMATOLOGY ASSOCIATES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NORTHRIDGE DERMATOLOGY ASSOCIATES MEDICAL GROUP INC
Other - Org Name:FKA BERNARD RESNICK MD INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-886-3884
Mailing Address - Street 1:9535 RESEDA BOULEVARD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-6029
Mailing Address - Country:US
Mailing Address - Phone:818-886-3884
Mailing Address - Fax:818-886-5418
Practice Address - Street 1:9535 RESEDA BOULEVARD
Practice Address - Street 2:SUITE 304
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-6029
Practice Address - Country:US
Practice Address - Phone:818-886-3884
Practice Address - Fax:818-886-5418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W10554Medicare ID - Type Unspecified