Provider Demographics
NPI:1619351707
Name:EL SEGUNDO DERMATOLOGY, INC.
Entity Type:Organization
Organization Name:EL SEGUNDO DERMATOLOGY, INC.
Other - Org Name:GARDENA DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-906-2788
Mailing Address - Street 1:713 N. DOUGLAS ST.
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245
Mailing Address - Country:US
Mailing Address - Phone:310-906-2788
Mailing Address - Fax:310-906-2786
Practice Address - Street 1:713 N DOUGLAS ST.
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245
Practice Address - Country:US
Practice Address - Phone:310-906-2788
Practice Address - Fax:310-906-2786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100120719Medicaid