Healthcare Provider Details

I. General information

NPI: 1073334181
Provider Name (Legal Business Name): THE DERMATOLOGY BAR, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CONCOURS ST. BLDG 1, SUITE 1201
ONTARIO CA
91764
US

IV. Provider business mailing address

3333 CONCOURS ST. BLDG 1, SUITE 1201
ONTARIO CA
91764
US

V. Phone/Fax

Practice location:
  • Phone: 909-476-4077
  • Fax:
Mailing address:
  • Phone: 909-476-4077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRITNEY KAUFMAN
Title or Position: CO-OWNER
Credential:
Phone: 909-476-4077