Healthcare Provider Details

I. General information

NPI: 1235738576
Provider Name (Legal Business Name): GOLDEN STATE DERMATOLOGY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6769 N FRESNO ST
FRESNO CA
93710-3715
US

IV. Provider business mailing address

355 LENNON LN STE 255
WALNUT CREEK CA
94598-2496
US

V. Phone/Fax

Practice location:
  • Phone: 559-435-0337
  • Fax:
Mailing address:
  • Phone: 925-932-7704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY THOMAS BORTZ
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 925-932-7704