Healthcare Provider Details

I. General information

NPI: 1497125264
Provider Name (Legal Business Name): BRIAN E DUBOW M D A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N ROXBURY DR SUITE 204
BEVERLY HILLS CA
90210-5027
US

IV. Provider business mailing address

435 N ROXBURY DR SUITE 204
BEVERLY HILLS CA
90210-5027
US

V. Phone/Fax

Practice location:
  • Phone: 310-275-8855
  • Fax: 323-848-4290
Mailing address:
  • Phone: 310-275-8855
  • Fax: 323-848-4290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN E DUBOW
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-275-8855