Provider Demographics
NPI:1578669545
Name:ADVANCED DERMATOLOGY THOMAS J. HOFFMANN MD SURGICAL&MEDICAL OFFICE INC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY THOMAS J. HOFFMANN MD SURGICAL&MEDICAL OFFICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HOFFMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-496-9602
Mailing Address - Street 1:29798 HAUN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6541
Mailing Address - Country:US
Mailing Address - Phone:909-496-9602
Mailing Address - Fax:760-242-5599
Practice Address - Street 1:18145 US HIGHWAY 18 STE A
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2210
Practice Address - Country:US
Practice Address - Phone:760-240-7546
Practice Address - Fax:760-242-5599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89986261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G551381Medicaid
CAA89986Medicare UPIN
CAZZZ04977ZMedicare PIN
CA00G55138Medicare ID - Type Unspecified