Healthcare Provider Details

I. General information

NPI: 1174898654
Provider Name (Legal Business Name): GREENBRAE DERMATOLOGY, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S ELISEO DR STE 207
GREENBRAE CA
94904-2015
US

IV. Provider business mailing address

1300 S ELISEO DR STE 207
GREENBRAE CA
94904-2015
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-0550
  • Fax: 415-925-9062
Mailing address:
  • Phone: 415-925-0550
  • Fax: 415-925-9062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA97783
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberG53455
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA97783
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA97783
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG53455
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA97783
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG53455
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA97783
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG40606
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberG40606
License Number StateCA
# 11
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG40606
License Number StateCA
# 12
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG53455
License Number StateCA

VIII. Authorized Official

Name: MRS. LUCRETIA ANN LEWITT
Title or Position: PRACTICE MANAGER
Credential:
Phone: 415-925-0550