Healthcare Provider Details

I. General information

NPI: 1063608107
Provider Name (Legal Business Name): NEWPORT COAST DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 MACARTHUR BLVD SUITE 228
NEWPORT BEACH CA
92660-3058
US

IV. Provider business mailing address

3991 MACARTHUR BLVD SUITE 228
NEWPORT BEACH CA
92660-3058
US

V. Phone/Fax

Practice location:
  • Phone: 949-863-0988
  • Fax: 949-863-0088
Mailing address:
  • Phone: 949-863-0988
  • Fax: 949-863-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA61446
License Number StateCA

VIII. Authorized Official

Name: DR. GRACE LIU
Title or Position: DR.
Credential: M.D.
Phone: 949-863-0988