Healthcare Provider Details

I. General information

NPI: 1598955791
Provider Name (Legal Business Name): ELITE MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 ROSE AVE
DANVILLE CA
94526-3320
US

IV. Provider business mailing address

360 ROSE AVE
DANVILLE CA
94526-3320
US

V. Phone/Fax

Practice location:
  • Phone: 717-805-0663
  • Fax:
Mailing address:
  • Phone: 717-805-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA99366
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA99986
License Number StateCA

VIII. Authorized Official

Name: DR. SONIA BADRESHIA
Title or Position: CEO
Credential: MD
Phone: 717-805-0663