Healthcare Provider Details

I. General information

NPI: 1083120992
Provider Name (Legal Business Name): MEDICAL DERMATOLOGY & COSMETIC CLINIC OF NORTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 UNIVERSITY AVE STE 200
SACRAMENTO CA
95825
US

IV. Provider business mailing address

650 UNIVERSITY AVE STE 200
SACRAMENTO CA
95825-6726
US

V. Phone/Fax

Practice location:
  • Phone: 916-771-7700
  • Fax:
Mailing address:
  • Phone:
  • 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 Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PANTEA HASHEMI
Title or Position: FOUNDER
Credential: MD
Phone: 916-571-5200