Provider Demographics
NPI:1336220540
Name:ADVANCED DERMATOLOGY INC.
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY INC.
Other - Org Name:ADVANCED DERMATOLOGY OF SAN CLEMENTE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOINFAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-240-2827
Mailing Address - Street 1:34213 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2875
Mailing Address - Country:US
Mailing Address - Phone:952-240-2827
Mailing Address - Fax:949-248-4587
Practice Address - Street 1:34213 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629
Practice Address - Country:US
Practice Address - Phone:949-248-4547
Practice Address - Fax:949-248-4587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92449207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty