MEDICARE: DERMATOLOGY SPA MED INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1356094676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY SPA MED INC

Provider Business Mailing Address
First Line	:	6000 PHYSICIANS BLVD STE 210
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93301-1215
Country	:	US
Telephone Number	:	661-327-4499
Fax Number	:	661-215-6387

Provider Business Practice Location Address
First Line	:	300 JAMES WAY STE 140
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2874
Country	:	US
Telephone Number	:	805-574-1000
Fax Number	:	805-574-1300

Authorized Official
Title or Position	:	CEO
Name	:	NOEL CABEZZAS
Credential	:
Telephone Number	:	661-327-4499

Provider Enumeration Date	:	01/27/2022
Last Update Date	:	01/27/2022

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Directions to “DERMATOLOGY SPA MED INC ” Practice Location

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