Healthcare Provider Details

I. General information

NPI: 1972831998
Provider Name (Legal Business Name): SAN DIEGO SKIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 REGENTS PARK ROW SUITE 300
LA JOLLA CA
92037-9124
US

IV. Provider business mailing address

4150 REGENTS PARK ROW SUITE 300
LA JOLLA CA
92037-9124
US

V. Phone/Fax

Practice location:
  • Phone: 858-909-9000
  • Fax: 858-909-9009
Mailing address:
  • Phone: 858-909-9000
  • Fax: 858-909-9009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA83432
License Number StateCA

VIII. Authorized Official

Name: M. MARK MOFID
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-909-9000