1245369941 NPI number — TELEGRAPH DERMATOLOGY MEDICAL GROUP INC

Table of content: (NPI 1245369941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245369941 NPI number — TELEGRAPH DERMATOLOGY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TELEGRAPH DERMATOLOGY MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245369941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8337 TELEGRAPH RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
PICO RIVERA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90660-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-806-1321
Provider Business Mailing Address Fax Number:
562-806-0801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8337 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
PICO RIVERA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90660-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-806-1321
Provider Business Practice Location Address Fax Number:
562-806-0801
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CANON
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
BASCO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-806-1321

Provider Taxonomy Codes

  • Taxonomy code: 207NS0135X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05D0552524 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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