Provider Demographics
NPI:1508441247
Name:INTEGRATED DERMATOLOGY OF SANTA ROSA, PC
Entity Type:Organization
Organization Name:INTEGRATED DERMATOLOGY OF SANTA ROSA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED GROUP OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:T
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-314-2000
Mailing Address - Street 1:4700 EXCHANGE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4450
Mailing Address - Country:US
Mailing Address - Phone:561-314-2000
Mailing Address - Fax:
Practice Address - Street 1:6574 OAKMONT DR STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-5958
Practice Address - Country:US
Practice Address - Phone:707-579-4239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty