Provider Demographics
NPI:1396400230
Name:SUBLIME MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SUBLIME MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:SUBLIME MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:DAWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-367-1115
Mailing Address - Street 1:7095 INDIANA AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4159
Mailing Address - Country:US
Mailing Address - Phone:951-218-9910
Mailing Address - Fax:888-561-4883
Practice Address - Street 1:255 TERRACINA BLVD STE 206
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-792-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-05
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty