Healthcare Provider Details

I. General information

NPI: 1285983197
Provider Name (Legal Business Name): INGRID ROSEBOROUGH, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WEBSTER ST STE 509
OAKLAND CA
94609-3149
US

IV. Provider business mailing address

3300 WEBSTER ST STE 509
OAKLAND CA
94609-3149
US

V. Phone/Fax

Practice location:
  • Phone: 510-452-4900
  • Fax: 510-452-2152
Mailing address:
  • Phone: 510-452-4900
  • Fax: 510-452-2152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA92548
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA92548
License Number StateCA

VIII. Authorized Official

Name: INGRID ROSEBOROUGH
Title or Position: OWNER
Credential: MD
Phone: 510-452-4900