Provider Demographics
NPI:1447220215
Name:EAST BAY DERMATOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:EAST BAY DERMATOLOGY MEDICAL GROUP INC
Other - Org Name:CENTER FOR DERMATOLOGY COSMETIC & LASER SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARMEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-797-4111
Mailing Address - Street 1:2557 MOWRY AVE
Mailing Address - Street 2:STE 34
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538
Mailing Address - Country:US
Mailing Address - Phone:510-797-4111
Mailing Address - Fax:510-797-3320
Practice Address - Street 1:2557 MOWRY AVE
Practice Address - Street 2:STE 34 AND STE 25
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-797-4111
Practice Address - Fax:510-797-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty