Provider Demographics
NPI:1568561256
Name:CITY OF ANGELS DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:CITY OF ANGELS DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-261-4963
Mailing Address - Street 1:4712 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 665
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-651-8240
Mailing Address - Fax:310-651-8254
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 1135 E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-651-8240
Practice Address - Fax:310-651-8254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19188Medicare ID - Type Unspecified