Provider Demographics
NPI:1245369941
Name:TELEGRAPH DERMATOLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:TELEGRAPH DERMATOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:BASCO
Authorized Official - Last Name:CANON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-806-1321
Mailing Address - Street 1:8337 TELEGRAPH RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4909
Mailing Address - Country:US
Mailing Address - Phone:563-806-1321
Mailing Address - Fax:562-806-0801
Practice Address - Street 1:8337 TELEGRAPH RD
Practice Address - Street 2:SUITE 210
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4909
Practice Address - Country:US
Practice Address - Phone:563-806-1321
Practice Address - Fax:562-806-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0552524OtherCLIA
CAA25957Medicare UPIN
CAW3881Medicare ID - Type UnspecifiedTELEGRAPH DERM MED GRP