Provider Demographics
NPI:1790134047
Name:SPECTRUM SKIN CANCER CARE INC
Entity Type:Organization
Organization Name:SPECTRUM SKIN CANCER CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ASIF
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-702-7602
Mailing Address - Street 1:517 N MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5016
Mailing Address - Country:US
Mailing Address - Phone:909-702-7602
Mailing Address - Fax:
Practice Address - Street 1:425 E HOLYOKE PL
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1979
Practice Address - Country:US
Practice Address - Phone:909-702-7602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty