Provider Demographics
NPI:1407950785
Name:BERNARDO DERMATOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BERNARDO DERMATOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-451-3311
Mailing Address - Street 1:15525 POMERADO RD
Mailing Address - Street 2:SUITE A2
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2435
Mailing Address - Country:US
Mailing Address - Phone:858-451-3311
Mailing Address - Fax:858-451-1142
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE A2
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:858-451-3311
Practice Address - Fax:858-451-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41388207N00000X, 207ND0101X
CAG49647207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15248Medicare ID - Type Unspecified
A48556Medicare UPIN