Provider Demographics
NPI:1568527893
Name:ADVANCED AESTHETIC DERMATOLOGY
Entity Type:Organization
Organization Name:ADVANCED AESTHETIC DERMATOLOGY
Other - Org Name:CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:BITTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:408-358-5757
Mailing Address - Street 1:14651 SO BASCOM AVE 200
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032
Mailing Address - Country:US
Mailing Address - Phone:408-358-5757
Mailing Address - Fax:408-358-8951
Practice Address - Street 1:14651 SO BASCOM AVE 200
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032
Practice Address - Country:US
Practice Address - Phone:408-358-5757
Practice Address - Fax:408-358-8951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50914207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G509140Medicare PIN
A451845Medicare UPIN