Healthcare Provider Details

I. General information

NPI: 1073152112
Provider Name (Legal Business Name): AGAPE DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18800 MAIN ST STE 111
HUNTINGTON BEACH CA
92648-1717
US

IV. Provider business mailing address

18800 MAIN ST STE 111
HUNTINGTON BEACH CA
92648-1717
US

V. Phone/Fax

Practice location:
  • Phone: 714-961-9119
  • Fax: 714-951-9149
Mailing address:
  • Phone: 714-951-9119
  • Fax: 714-951-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TERESA ZAMARY
Title or Position: CEO
Credential: DO
Phone: 714-951-9119