Healthcare Provider Details

I. General information

NPI: 1952562258
Provider Name (Legal Business Name): JOSEPH F. SEDRAK M.D., A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 BROCKTON AVE STE 200
RIVERSIDE CA
92501-4026
US

IV. Provider business mailing address

11751 ALMOND CT
LOMA LINDA CA
92354-3640
US

V. Phone/Fax

Practice location:
  • Phone: 951-858-4595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA84538
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA84538
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA84538
License Number StateCA

VIII. Authorized Official

Name: DR. JOSEPH F SEDRAK
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 909-796-9544