Provider Demographics
NPI:1437422391
Name:MUNYON DERMATOLOGY
Entity Type:Organization
Organization Name:MUNYON DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-579-7277
Mailing Address - Street 1:215 N SAN MATEO DR STE 1
Mailing Address - Street 2:SUITE1
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2674
Mailing Address - Country:US
Mailing Address - Phone:650-579-7277
Mailing Address - Fax:650-579-3745
Practice Address - Street 1:215 N SAN MATEO DR STE 1
Practice Address - Street 2:SUITE1
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2674
Practice Address - Country:US
Practice Address - Phone:650-579-7277
Practice Address - Fax:650-579-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30666207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26183Medicare UPIN