Healthcare Provider Details

I. General information

NPI: 1881631711
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3629 VISTA WAY
OCEANSIDE CA
92056-4522
US

IV. Provider business mailing address

3629 VISTA WAY
OCEANSIDE CA
92056-4522
US

V. Phone/Fax

Practice location:
  • Phone: 760-828-9200
  • Fax: 760-828-9141
Mailing address:
  • Phone: 760-828-9201
  • Fax: 760-828-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: JANE LISK
Title or Position: ADMINISTRATOR
Credential:
Phone: 760-757-7546