Healthcare Provider Details

I. General information

NPI: 1306940465
Provider Name (Legal Business Name): DERMATOLOGICARE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 N CAMDEN DR SUITE 1001
BEVERLY HILLS CA
90210-4532
US

IV. Provider business mailing address

414 N CAMDEN DR SUITE 1001
BEVERLY HILLS CA
90210-4532
US

V. Phone/Fax

Practice location:
  • Phone: 310-247-0337
  • Fax: 310-247-0343
Mailing address:
  • Phone: 310-247-0337
  • Fax: 310-247-0343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG77137
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG77137
License Number StateCA

VIII. Authorized Official

Name: REZA BABAPOUR
Title or Position: MD OWNER
Credential: MD
Phone: 310-247-0337