Healthcare Provider Details

I. General information

NPI: 1871326363
Provider Name (Legal Business Name): O & P DERMATOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3028 E COAST HWY
CORONA DEL MAR CA
92625-2209
US

IV. Provider business mailing address

20270 KLINE LN
YORBA LINDA CA
92887-3269
US

V. Phone/Fax

Practice location:
  • Phone: 714-598-9939
  • Fax:
Mailing address:
  • Phone: 714-598-9939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OMEED AHADIAT
Title or Position: PRESIDENT
Credential: MD
Phone: 714-598-9939