Provider Demographics
NPI:1407198005
Name:PRECISION DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:PRECISION DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-202-1540
Mailing Address - Street 1:2100 WEBSTER ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2373
Mailing Address - Country:US
Mailing Address - Phone:415-202-1540
Mailing Address - Fax:
Practice Address - Street 1:7064 CORLINE CT
Practice Address - Street 2:SUITE C
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4528
Practice Address - Country:US
Practice Address - Phone:415-202-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRECISION DERMATOLOGY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96572207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty