Provider Demographics
NPI:1962829457
Name:BLUE HARBOR DERMATOLOGY INC
Entity type:Organization
Organization Name:BLUE HARBOR DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-828-2012
Mailing Address - Street 1:1501 SUPERIOR AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 SUPERIOR AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3600
Practice Address - Country:US
Practice Address - Phone:214-395-2221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12076207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty