Healthcare Provider Details

I. General information

NPI: 1114357191
Provider Name (Legal Business Name): KATELYN URBAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 NEWPORT CENTER DR STE 158
NEWPORT BEACH CA
92660-0934
US

IV. Provider business mailing address

13400 E RIVER RD
COLUMBIA STATION OH
44028-9535
US

V. Phone/Fax

Practice location:
  • Phone: 440-585-6500
  • Fax:
Mailing address:
  • Phone: 440-213-6831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number20A21877
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number20A21877
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20A21877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: