Healthcare Provider Details

I. General information

NPI: 1154517993
Provider Name (Legal Business Name): BOSTON DERMATOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 W BADILLO ST
COVINA CA
91723-1906
US

IV. Provider business mailing address

262 W BADILLO ST
COVINA CA
91723-1906
US

V. Phone/Fax

Practice location:
  • Phone: 626-653-2525
  • Fax: 626-653-0808
Mailing address:
  • Phone: 626-653-2525
  • Fax: 626-653-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA74086
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA74086
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA74086
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA74086
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA74086
License Number StateCA

VIII. Authorized Official

Name: SAEED NAWAZ JAFFER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-653-2525