Provider Demographics
NPI:1720370166
Name:ADVANCED MEDICAL AND SURGICAL DERMATOLOGY CORPORATION
Entity Type:Organization
Organization Name:ADVANCED MEDICAL AND SURGICAL DERMATOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-259-0131
Mailing Address - Street 1:1099 D ST STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2893
Mailing Address - Country:US
Mailing Address - Phone:415-259-0131
Mailing Address - Fax:415-259-0133
Practice Address - Street 1:1099 D ST STE 204
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2893
Practice Address - Country:US
Practice Address - Phone:415-259-0131
Practice Address - Fax:415-259-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65185207N00000X
CAA65186207ND0101X, 207ND0900X, 207NI0002X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty