Healthcare Provider Details

I. General information

NPI: 1841487600
Provider Name (Legal Business Name): C MALEKI MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 11/06/2022
Certification Date: 11/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 LYNN RD SUITE 105
THOUSAND OAKS CA
91360-1901
US

IV. Provider business mailing address

2230 LYNN RD SUITE 105
THOUSAND OAKS CA
91360-1901
US

V. Phone/Fax

Practice location:
  • Phone: 805-496-6611
  • Fax: 805-494-6756
Mailing address:
  • Phone: 805-496-6611
  • Fax: 805-494-6756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA36282
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA36282
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA36282
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA36282
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA36282
License Number StateCA

VIII. Authorized Official

Name: COMRON MALEKI
Title or Position: OWNER
Credential: MD
Phone: 805-496-6611