Provider Demographics
NPI:1578597001
Name:DIAMOND BAR DERMATOLOGY CENTER
Entity Type:Organization
Organization Name:DIAMOND BAR DERMATOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-860-7600
Mailing Address - Street 1:P.O. BOX 15807
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209
Mailing Address - Country:US
Mailing Address - Phone:909-860-7600
Mailing Address - Fax:909-860-7460
Practice Address - Street 1:1200 S DIAMOND BAR BLVD
Practice Address - Street 2:SUITE #201
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2298
Practice Address - Country:US
Practice Address - Phone:909-860-7600
Practice Address - Fax:909-860-7460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG044761207N00000X, 207ND0101X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18423Medicare ID - Type UnspecifiedPROVIDER NUMBER