Provider Demographics
NPI:1740410182
Name:PACIFIC DERMATOLOGY INSTITUTE
Entity Type:Organization
Organization Name:PACIFIC DERMATOLOGY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:PIERCE
Authorized Official - Last Name:MUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-354-2220
Mailing Address - Street 1:101 E REDLANDS BLVD STE 284
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4721
Mailing Address - Country:US
Mailing Address - Phone:909-707-5979
Mailing Address - Fax:909-712-0664
Practice Address - Street 1:770 MAGNOLIA AVE STE 1H
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3121
Practice Address - Country:US
Practice Address - Phone:951-734-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty