Healthcare Provider Details

I. General information

NPI: 1457538415
Provider Name (Legal Business Name): S. GAYLE WIDYOLAR, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MONTECITO DR
CORONA DEL MAR CA
92625-1017
US

IV. Provider business mailing address

21 MONTECITO DR
CORONA DEL MAR CA
92625-1017
US

V. Phone/Fax

Practice location:
  • Phone: 949-760-2552
  • Fax: 949-706-3808
Mailing address:
  • Phone: 949-760-2552
  • Fax: 949-706-3808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHEILA GAYLE WIDYOLAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-760-2552