Healthcare Provider Details

I. General information

NPI: 1356561682
Provider Name (Legal Business Name): SOLANO DERMATOLOGY ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NUT TREE RD SUITE 260
VACAVILLE CA
95687-4669
US

IV. Provider business mailing address

2290 SACRAMENTO ST
VALLEJO CA
94590-2929
US

V. Phone/Fax

Practice location:
  • Phone: 707-452-7222
  • Fax: 707-452-8507
Mailing address:
  • Phone: 707-643-5785
  • Fax: 707-643-5876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number019731
License Number StateCA

VIII. Authorized Official

Name: MS. SANDIE FOWLER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 707-556-5991