Healthcare Provider Details

I. General information

NPI: 1740410182
Provider Name (Legal Business Name): PACIFIC DERMATOLOGY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MAGNOLIA AVE STE 1H
CORONA CA
92879-3121
US

IV. Provider business mailing address

1200 CALIFORNIA ST STE 210
REDLANDS CA
92374-2948
US

V. Phone/Fax

Practice location:
  • Phone: 951-734-8989
  • Fax:
Mailing address:
  • Phone: 909-693-3424
  • Fax:

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

VIII. Authorized Official

Name: DR. BRADLEY PIERCE MUDGE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-354-2220