Healthcare Provider Details

I. General information

NPI: 1205623550
Provider Name (Legal Business Name): CALIFORNIA DERMATOLOGY INSTITUTE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W CATALINA DR
YUMA AZ
85364-8112
US

IV. Provider business mailing address

3095 OLD CONEJO RD
THOUSAND OAKS CA
91320-2130
US

V. Phone/Fax

Practice location:
  • Phone: 805-298-7034
  • Fax: 805-298-7139
Mailing address:
  • Phone: 805-298-7034
  • Fax: 805-298-7139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: NAVID EZRA
Title or Position: OWNER
Credential:
Phone: 805-222-5803