Healthcare Provider Details

I. General information

NPI: 1821096942
Provider Name (Legal Business Name): DR. MAKI C. GOSKOWICZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. MAKI CHRISTINE OKAMURA

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8860 CENTER DR STE 300
LA MESA CA
91942-3068
US

IV. Provider business mailing address

8860 CENTER DR STE 300
LA MESA CA
91942-3068
US

V. Phone/Fax

Practice location:
  • Phone: 619-462-1670
  • Fax: 619-462-3209
Mailing address:
  • Phone: 619-462-1670
  • Fax: 619-462-3209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberG73340
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG73340
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG73340
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: