Provider Demographics
NPI:1346307105
Name:DELTA DERMATOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:DELTA DERMATOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-673-3582
Mailing Address - Street 1:310 N PRAIRIE AVE
Mailing Address - Street 2:SUITE 412
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301
Mailing Address - Country:US
Mailing Address - Phone:310-673-3582
Mailing Address - Fax:310-677-5466
Practice Address - Street 1:310 N PRAIRIE AVE
Practice Address - Street 2:SUITE 412
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301
Practice Address - Country:US
Practice Address - Phone:310-673-3582
Practice Address - Fax:310-677-5466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G491641Medicaid
CA00G491641Medicaid
CAW11323Medicare ID - Type Unspecified