Healthcare Provider Details

I. General information

NPI: 1639368368
Provider Name (Legal Business Name): HUNTINGTON BEACH DERMATOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 NEWMAN AVE STE C
HUNTINGTON BEACH CA
92647-7042
US

IV. Provider business mailing address

8101 NEWMAN AVE STE C
HUNTINGTON BEACH CA
92647-7042
US

V. Phone/Fax

Practice location:
  • Phone: 714-848-0770
  • Fax: 714-848-6643
Mailing address:
  • Phone: 714-848-0770
  • Fax: 714-848-6643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG237020
License Number StateCA

VIII. Authorized Official

Name: PATRICIA LEMONNIER
Title or Position: OFFICE MANAGER
Credential:
Phone: 714-848-0770