Provider Demographics
NPI:1780963991
Name:LAKESIDE DERMATOLOGY - A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:LAKESIDE DERMATOLOGY - A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:415-317-7261
Mailing Address - Street 1:1 SHRADER STREET
Mailing Address - Street 2:#640
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117
Mailing Address - Country:US
Mailing Address - Phone:415-422-0000
Mailing Address - Fax:415-424-4140
Practice Address - Street 1:1 SHRADER STREET
Practice Address - Street 2:#640
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117
Practice Address - Country:US
Practice Address - Phone:415-422-0000
Practice Address - Fax:415-424-4140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9018207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFO220AMedicare PIN