Provider Demographics
NPI:1962509109
Name:DERMATOLOGY SURGICAL & MEDICAL GROUP
Entity Type:Organization
Organization Name:DERMATOLOGY SURGICAL & MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:NILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-476-2444
Mailing Address - Street 1:1661 SOQUEL DR
Mailing Address - Street 2:BUILDING E
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1709
Mailing Address - Country:US
Mailing Address - Phone:831-476-2444
Mailing Address - Fax:831-476-3271
Practice Address - Street 1:1661 SOQUEL DR
Practice Address - Street 2:BUILDING E
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065
Practice Address - Country:US
Practice Address - Phone:831-476-2444
Practice Address - Fax:831-476-3271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053090Medicaid
CAZZZ35766ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER