Healthcare Provider Details

I. General information

NPI: 1700371275
Provider Name (Legal Business Name): ICECREAMWALA DERMATOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 WEBSTER ST STE 101
BERKELEY CA
94705
US

IV. Provider business mailing address

2435 WEBSTER ST STE 101
BERKELEY CA
94705-2050
US

V. Phone/Fax

Practice location:
  • Phone: 510-646-8070
  • Fax: 833-484-7048
Mailing address:
  • Phone: 510-646-8070
  • Fax: 833-484-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DEVIKA ICECREAMWALA
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 510-646-8070