Healthcare Provider Details

I. General information

NPI: 1285926543
Provider Name (Legal Business Name): COAST DERMATOLOGY MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23550 HAWTHORNE BLVD #200
TORRANCE CA
90505-4722
US

IV. Provider business mailing address

23550 HAWTHORNE BLVD STE 200
TORRANCE CA
90505-4722
US

V. Phone/Fax

Practice location:
  • Phone: 310-373-2636
  • Fax: 310-373-2633
Mailing address:
  • Phone: 310-534-9131
  • Fax: 310-534-9132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. MARK KEVIN HOROWITZ
Title or Position: PRESIDENT
Credential: D.O.
Phone: 310-373-2636