Provider Demographics
NPI:1790890085
Name:CORONA DERMATOLOGY CENTER INC.
Entity Type:Organization
Organization Name:CORONA DERMATOLOGY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-860-7600
Mailing Address - Street 1:PO BOX 15807
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209-1807
Mailing Address - Country:US
Mailing Address - Phone:909-860-7600
Mailing Address - Fax:909-860-2757
Practice Address - Street 1:1810 FULLERTON AVE
Practice Address - Street 2:STE 101
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3103
Practice Address - Country:US
Practice Address - Phone:951-734-7900
Practice Address - Fax:909-860-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG044761207N00000X, 207ND0101X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04071ZMedicare PIN