MEDICARE: COMPREHENSIVE DERMATOLOGY OF LONG BEACH PC

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	:	1720356827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPREHENSIVE DERMATOLOGY OF LONG BEACH PC

Provider Business Mailing Address
First Line	:	3736 ATLANTIC AVE
Second Line	:	SUITE 101
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3492
Country	:	US
Telephone Number	:	562-256-9929
Fax Number	:	562-256-9946

Provider Business Practice Location Address
First Line	:	3736 ATLANTIC AVE
Second Line	:	SUITE 101
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3492
Country	:	US
Telephone Number	:	562-256-9929
Fax Number	:	562-256-9946

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. JILL H JAVAHERY
Credential	:	MD
Telephone Number	:	562-256-9929

Provider Enumeration Date	:	12/05/2011
Last Update Date	:	02/21/2012

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