Healthcare Provider Details

I. General information

NPI: 1407950785
Provider Name (Legal Business Name): BERNARDO DERMATOLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD SUITE A2
POWAY CA
92064-2435
US

IV. Provider business mailing address

15525 POMERADO RD SUITE A2
POWAY CA
92064-2435
US

V. Phone/Fax

Practice location:
  • Phone: 858-451-3311
  • Fax: 858-451-1142
Mailing address:
  • Phone: 858-451-3311
  • Fax: 858-451-1142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG41388
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberG41388
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG49647
License Number StateCA

VIII. Authorized Official

Name: RUTH ANN LARSON
Title or Position: PRESIDENT
Credential: MD
Phone: 858-451-3311