Provider Demographics
NPI:1356425888
Name:DOWNEY DERMATOLOGIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:DOWNEY DERMATOLOGIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GREESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-869-2478
Mailing Address - Street 1:11480 BROOKSHIRE AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-5022
Mailing Address - Country:US
Mailing Address - Phone:562-869-2478
Mailing Address - Fax:562-861-1229
Practice Address - Street 1:11480 BROOKSHIRE AVE STE 109
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5022
Practice Address - Country:US
Practice Address - Phone:562-869-2478
Practice Address - Fax:562-861-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA070008435OtherRAILROAD MEDICARE
CAGR0085810Medicaid
CA070008463OtherRAILROAD MEDICARE
CAZZZ98655ZOtherBLUE SHIELD
CADD1100OtherRAILROAD MEDICARE
CADD1100OtherRAILROAD MEDICARE
CAA40427Medicare UPIN
CA070008463OtherRAILROAD MEDICARE
CAZZZ98655ZOtherBLUE SHIELD