Healthcare Provider Details

I. General information

NPI: 1194838441
Provider Name (Legal Business Name): GROSSMONT DERMATOLOGY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
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
91942-7001
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 Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MONICA DEL VALLE
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 619-462-1670