Provider Demographics
NPI:1700138906
Name:CT DERMATOLOGY & ASSOCIATES, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CT DERMATOLOGY & ASSOCIATES, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARCOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-894-5616
Mailing Address - Street 1:15336 DEVONSHIRE ST. #1
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-2766
Mailing Address - Country:US
Mailing Address - Phone:818-894-5616
Mailing Address - Fax:818-893-4872
Practice Address - Street 1:15336 DEVONSHIRE ST. #1
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2766
Practice Address - Country:US
Practice Address - Phone:818-894-5616
Practice Address - Fax:818-893-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38005207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CM0072Medicare UPIN