Provider Demographics
NPI:1356778476
Name:MARINA DERMATOLOGY ASSOCIATES
Entity type:Organization
Organization Name:MARINA DERMATOLOGY ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALOMARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-827-2653
Mailing Address - Street 1:4644 LINCOLN BLVD
Mailing Address - Street 2:SUITE 552
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6313
Mailing Address - Country:US
Mailing Address - Phone:310-827-2653
Mailing Address - Fax:310-823-1984
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 552
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:310-827-2653
Practice Address - Fax:310-823-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15116207N00000X
CAG45892207N00000X, 207N00000X
CA18086207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty