Healthcare Provider Details

I. General information

NPI: 1154592368
Provider Name (Legal Business Name): FOOTHILL DERMATOLOGY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E FOOTHILL BLVD STE 100
GLENDORA CA
91740-4000
US

IV. Provider business mailing address

2301 E FOOTHILL BLVD STE 100
GLENDORA CA
91740-4000
US

V. Phone/Fax

Practice location:
  • Phone: 626-852-3376
  • Fax: 626-852-3375
Mailing address:
  • Phone: 626-852-3376
  • Fax: 626-852-3375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA73248
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA73218
License Number StateCA

VIII. Authorized Official

Name: DR. AMARPAUL S SIDHU
Title or Position: OWNER
Credential: M.D.,
Phone: 626-852-3376