Healthcare Provider Details

I. General information

NPI: 1316136740
Provider Name (Legal Business Name): DERMATOLOGY PROFESSIONALS INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10672 WEXFORD STREET SUITE 205
SAN DIEGO CA
92131-3974
US

IV. Provider business mailing address

10672 WEXFORD STREET SUITE 205
SAN DIEGO CA
92131-3974
US

V. Phone/Fax

Practice location:
  • Phone: 858-693-3000
  • Fax: 858-693-3700
Mailing address:
  • Phone: 858-693-3000
  • Fax: 858-693-3700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA79823
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA79823
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA79823
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberA79823
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA79823
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA79823
License Number StateCA

VIII. Authorized Official

Name: DR. BRYAN CHEN
Title or Position: CEO
Credential: M.D.
Phone: 858-693-3000