Provider Demographics
NPI:1619186731
Name:CRYSTAL COVE DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:CRYSTAL COVE DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGUERITE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRITELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-640-9633
Mailing Address - Street 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 602
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7721
Mailing Address - Country:US
Mailing Address - Phone:949-640-9633
Mailing Address - Fax:949-640-9677
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 602
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-640-9633
Practice Address - Fax:949-640-9677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG076233174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG76233OtherSTATE LICENSE
CAG76233Medicare ID - Type UnspecifiedMEDICARE
CAG02214Medicare UPIN