Healthcare Provider Details

I. General information

NPI: 1164425054
Provider Name (Legal Business Name): ESCONDIDO DERMATOLOGY, INC A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 W MISSION AVE STE 101
ESCONDIDO CA
92025-1602
US

IV. Provider business mailing address

504 W MISSION AVE STE 101
ESCONDIDO CA
92025-1602
US

V. Phone/Fax

Practice location:
  • Phone: 760-747-1980
  • Fax: 760-747-2045
Mailing address:
  • Phone: 760-747-1980
  • Fax: 760-747-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA070199
License Number StateCA

VIII. Authorized Official

Name: NANCY P CHEN
Title or Position: M.D.
Credential: M.D.
Phone: 760-747-1980