Provider Demographics
NPI:1962639583
Name:SOLANO DERMATOLOGY ASSOCIATES INC
Entity Type:Organization
Organization Name:SOLANO DERMATOLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:GEISSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-643-5785
Mailing Address - Street 1:2290 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2929
Mailing Address - Country:US
Mailing Address - Phone:707-643-5785
Mailing Address - Fax:707-643-8190
Practice Address - Street 1:6431 FAIRMOUNT AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3655
Practice Address - Country:US
Practice Address - Phone:510-527-8865
Practice Address - Fax:510-527-4123
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLANO DERMATOLOGY ASSOCIATES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0023150Medicaid
CAGR0023150Medicaid