Provider Demographics
NPI:1700860871
Name:GOLDEN STATE DERMATOLOGY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:GOLDEN STATE DERMATOLOGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BORTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-932-7704
Mailing Address - Street 1:370 N WIGET LN STE 250
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2488
Mailing Address - Country:US
Mailing Address - Phone:925-945-7005
Mailing Address - Fax:925-954-1822
Practice Address - Street 1:355 LENNON LN STE 255
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2496
Practice Address - Country:US
Practice Address - Phone:925-932-7704
Practice Address - Fax:925-932-7752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA487440OtherLICENSE
CA05D096539OtherCLIA NUMBER
CABB2515394OtherDEA
CA05D096539OtherCLIA NUMBER
CAF24158Medicare UPIN