Provider Demographics
NPI:1023289840
Name:DESERT DERMATOLOGY MEDICAL ASSOIATES INC
Entity type:Organization
Organization Name:DESERT DERMATOLOGY MEDICAL ASSOIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-346-4262
Mailing Address - Street 1:72301 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE101
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-8007
Mailing Address - Country:US
Mailing Address - Phone:760-346-4262
Mailing Address - Fax:760-340-9892
Practice Address - Street 1:72301 COUNTRY CLUB DR
Practice Address - Street 2:SUITE101
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-8007
Practice Address - Country:US
Practice Address - Phone:760-346-4262
Practice Address - Fax:760-340-9892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG057257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03127ZOtherMEDICARE PROVIDER NUMBER