Healthcare Provider Details

I. General information

NPI: 1386629905
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA DERMATOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E 17TH ST W-248
SANTA ANA CA
92701-2201
US

IV. Provider business mailing address

1125 E 17TH ST W-248
SANTA ANA CA
92701-2201
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-5151
  • Fax: 714-541-2016
Mailing address:
  • Phone: 714-547-5151
  • Fax: 714-547-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN A BARON
Title or Position: OWNER
Credential: MD
Phone: 714-547-5151