Healthcare Provider Details

I. General information

NPI: 1821167537
Provider Name (Legal Business Name): PACIFIC WEST DERMATOLOGY A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 WILSHIRE BLVD STE 106
BEVERLY HILLS CA
90211-1838
US

IV. Provider business mailing address

9001 WILSHIRE BLVD STE 106
BEVERLY HILLS CA
90211-1838
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-8885
  • Fax: 310-273-8662
Mailing address:
  • Phone: 310-273-8885
  • Fax: 310-273-8662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA71181
License Number StateCA

VIII. Authorized Official

Name: DR. JULIAN OMIDI
Title or Position: OWNER OPERATOR
Credential: M.D.
Phone: 310-927-3282