Provider Demographics
NPI:1407883770
Name:CALIFORNIA DERMATOLOGY CENTER
Entity Type:Organization
Organization Name:CALIFORNIA DERMATOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:LEDESMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-360-6661
Mailing Address - Street 1:602 N ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-3228
Mailing Address - Country:US
Mailing Address - Phone:310-200-8705
Mailing Address - Fax:
Practice Address - Street 1:23525 GOLDEN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2175
Practice Address - Country:US
Practice Address - Phone:909-860-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44761207N00000X, 207ND0101X, 207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
Not Answered207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17955AMedicare ID - Type UnspecifiedGROUP ID
CAW17955Medicare ID - Type UnspecifiedGARDEN GROVE GROUP ID