Provider Demographics
NPI:1972831998
Name:SAN DIEGO SKIN, INC.
Entity Type:Organization
Organization Name:SAN DIEGO SKIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:M.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MOFID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-909-9000
Mailing Address - Street 1:4150 REGENTS PARK ROW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9124
Mailing Address - Country:US
Mailing Address - Phone:858-909-9000
Mailing Address - Fax:858-909-9009
Practice Address - Street 1:4150 REGENTS PARK ROW
Practice Address - Street 2:SUITE 300
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9124
Practice Address - Country:US
Practice Address - Phone:858-909-9000
Practice Address - Fax:858-909-9009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83432261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical