Healthcare Provider Details

I. General information

NPI: 1467640284
Provider Name (Legal Business Name): EAST BAY DERMATOLOGY MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1158 JACKLIN RD
MILPITAS CA
95035-3700
US

IV. Provider business mailing address

2557 MOWRY AVE STE 34
FREMONT CA
94538-1614
US

V. Phone/Fax

Practice location:
  • Phone: 408-957-7676
  • Fax: 408-942-1342
Mailing address:
  • Phone: 510-797-4111
  • Fax: 510-797-3320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG53340
License Number StateCA

VIII. Authorized Official

Name: DR. SUNIL S. DHAWAN
Title or Position: SECRETARY OF THE CORPORATION
Credential: M.D.
Phone: 408-957-7676