Healthcare Provider Details

I. General information

NPI: 1669575551
Provider Name (Legal Business Name): DELMAR DERMATOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL SUITE #115
SAN DIEGO CA
92130
US

IV. Provider business mailing address

PO BOX 15807
BEVERLY HILLS CA
90209-1807
US

V. Phone/Fax

Practice location:
  • Phone: 858-259-9858
  • Fax:
Mailing address:
  • Phone: 909-860-7600
  • Fax: 909-860-2757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: GLENN N LEDESMA
Title or Position: OWNER
Credential: MD
Phone: 909-860-7600