Provider Demographics
NPI:1922486117
Name:PACIFIC DERMATOLOGY INSTITUTE
Entity Type:Organization
Organization Name:PACIFIC DERMATOLOGY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTOMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-362-2966
Mailing Address - Street 1:240 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7512
Mailing Address - Country:US
Mailing Address - Phone:946-644-2450
Mailing Address - Fax:946-644-2451
Practice Address - Street 1:240 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 105
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7512
Practice Address - Country:US
Practice Address - Phone:946-644-2450
Practice Address - Fax:946-644-2451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79221207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA79221CMedicare PIN
CAH66771Medicare UPIN