Provider Demographics
NPI:1518916527
Name:UCI DEPARTMENT OF DERMATOLOGY
Entity Type:Organization
Organization Name:UCI DEPARTMENT OF DERMATOLOGY
Other - Org Name:UC REGENTS OF CALIFORNIA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:UPS PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:UCI HEALTH
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVIDER RELATIONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-456-2986
Mailing Address - Street 1:PO BOX 31001-2462
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-2462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-7004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZP3020ZOtherBLUE SHIELD ID NUMBER
CAGR0009660Medicaid
CAGR0009660Medicaid