Provider Demographics
NPI:1811539026
Name:DERM-AUTHORITY GROUP LLC
Entity Type:Organization
Organization Name:DERM-AUTHORITY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-876-5476
Mailing Address - Street 1:13372 NEWPORT AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3426
Mailing Address - Country:US
Mailing Address - Phone:714-761-3901
Mailing Address - Fax:714-821-6392
Practice Address - Street 1:13372 NEWPORT AVE STE A
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3426
Practice Address - Country:US
Practice Address - Phone:714-761-3901
Practice Address - Fax:714-821-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies