Provider Demographics
NPI:1457396178
Name:DERMATOLOGY&LASER CENTER OF SAN DIEGO
Entity Type:Organization
Organization Name:DERMATOLOGY&LASER CENTER OF SAN DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-476-1200
Mailing Address - Street 1:319 F ST
Mailing Address - Street 2:102
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2666
Mailing Address - Country:US
Mailing Address - Phone:619-476-1200
Mailing Address - Fax:619-420-7849
Practice Address - Street 1:319 F ST
Practice Address - Street 2:102
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2666
Practice Address - Country:US
Practice Address - Phone:619-476-1200
Practice Address - Fax:619-420-7849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69750174400000X
CAA78399174400000X
CAC36597174400000X
CAA94658174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16018Medicare ID - Type Unspecified