Healthcare Provider Details

I. General information

NPI: 1497392492
Provider Name (Legal Business Name): PACIFICA DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 N PONDEROSA DR STE A117
CAMARILLO CA
93010-2468
US

IV. Provider business mailing address

2460 N PONDEROSA DR STE A117
CAMARILLO CA
93010-2468
US

V. Phone/Fax

Practice location:
  • Phone: 805-430-0002
  • Fax:
Mailing address:
  • Phone: 805-430-0002
  • Fax: 805-389-1245

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 Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE FIFER
Title or Position: D
Credential:
Phone: 805-484-2855