Healthcare Provider Details

I. General information

NPI: 1740485010
Provider Name (Legal Business Name): COMPREHENSIVE DERMATOLOGY CENTER OF PASADENA, A MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S FAIR OAKS AVE SUITE 200
PASADENA CA
91105-2613
US

IV. Provider business mailing address

625 S FAIR OAKS AVE SUITE 200
PASADENA CA
91105-2613
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-7790
  • Fax: 626-793-9018
Mailing address:
  • Phone: 626-793-7790
  • Fax: 626-793-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA80177
License Number StateCA

VIII. Authorized Official

Name: DR. HAN N. LEE
Title or Position: DIRECTOR
Credential: M.D.
Phone: 626-793-7790