Healthcare Provider Details

I. General information

NPI: 1962260208
Provider Name (Legal Business Name): DERM LOUNGE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 W KATELLA AVE
ANAHEIM CA
92804-6450
US

IV. Provider business mailing address

PO BOX 519
LAKE FOREST CA
92609-0519
US

V. Phone/Fax

Practice location:
  • Phone: 714-798-2900
  • Fax: 949-216-3232
Mailing address:
  • Phone: 714-798-2900
  • Fax: 949-216-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: HARRIS KHAN
Title or Position: PRESIDENT
Credential:
Phone: 714-337-9393