Provider Demographics
NPI:1184919011
Name:ADVANCED INSTITUTE OF DERMATOLOGY, INC
Entity type:Organization
Organization Name:ADVANCED INSTITUTE OF DERMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SICKINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-568-9300
Mailing Address - Street 1:41990 COOK ST # F1006
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-6100
Mailing Address - Country:US
Mailing Address - Phone:760-568-9300
Mailing Address - Fax:760-568-9331
Practice Address - Street 1:41990 COOK ST # F1006
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6100
Practice Address - Country:US
Practice Address - Phone:760-568-9300
Practice Address - Fax:760-568-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10108207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFM656Medicare PIN