Healthcare Provider Details

I. General information

NPI: 1053778274
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31469 RANCHO PUEBLO RD # 101
TEMECULA CA
92592-4834
US

IV. Provider business mailing address

3629 VISTA WAY
OCEANSIDE CA
92056-4522
US

V. Phone/Fax

Practice location:
  • Phone: 951-304-7546
  • Fax:
Mailing address:
  • Phone: 760-828-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14750
License Number StateCA

VIII. Authorized Official

Name: JANE LISK
Title or Position: ADMINISTRATOR
Credential:
Phone: 760-757-7546