Healthcare Provider Details

I. General information

NPI: 1033289574
Provider Name (Legal Business Name): SOUTH BAY SKIN & CANCER MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 LANDIS AVE THIRD FLOOR
CHULA VISTA CA
91910-2650
US

IV. Provider business mailing address

256 LANDIS AVE THIRD FLOOR
CHULA VISTA CA
91910-2650
US

V. Phone/Fax

Practice location:
  • Phone: 619-426-9600
  • Fax: 619-426-4112
Mailing address:
  • Phone: 619-426-9600
  • Fax: 619-426-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG42243
License Number StateCA

VIII. Authorized Official

Name: DR. PETER PAUL RULLAN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 619-426-9600