Healthcare Provider Details

I. General information

NPI: 1235671389
Provider Name (Legal Business Name): CALIFORNIA DERMATOLOGY INSTITUTE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 OLD CONEJO RD STE 200
THOUSAND OAKS CA
91320-2130
US

IV. Provider business mailing address

3095 OLD CONEJO RD, SUITE 200
THOUSAND OAKS CA
91320-2130
US

V. Phone/Fax

Practice location:
  • Phone: 805-222-5803
  • Fax:
Mailing address:
  • Phone: 805-222-5803
  • Fax: 805-222-0323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NAVID EZRA
Title or Position: MD
Credential: MD
Phone: 805-222-5803