1467640284 NPI number — EAST BAY DERMATOLOGY MEDICAL GROUP INC.

Table of content: (NPI 1467640284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467640284 NPI number — EAST BAY DERMATOLOGY MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST BAY 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:
6
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:
1467640284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2557 MOWRY AVE STE 34
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94538-1614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-797-4111
Provider Business Mailing Address Fax Number:
510-797-3320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1158 JACKLIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILPITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95035-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-957-7676
Provider Business Practice Location Address Fax Number:
408-942-1342
Provider Enumeration Date:
10/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DHAWAN
Authorized Official First Name:
SUNIL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
SECRETARY OF THE CORPORATION
Authorized Official Telephone Number:
408-957-7676

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G53340 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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