Provider Demographics
NPI:1013136357
Name:INTEGRATED DERMATOLOGY AND DERMATOPATHOLOGY, INC.
Entity Type:Organization
Organization Name:INTEGRATED DERMATOLOGY AND DERMATOPATHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:KEEYEUL
Authorized Official - Last Name:SUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-722-3555
Mailing Address - Street 1:11902 CANDOR ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6907
Mailing Address - Country:US
Mailing Address - Phone:562-714-5849
Mailing Address - Fax:
Practice Address - Street 1:1525 SUPERIOR AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3639
Practice Address - Country:US
Practice Address - Phone:949-722-3555
Practice Address - Fax:949-722-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86806207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty