Healthcare Provider Details

I. General information

NPI: 1083188221
Provider Name (Legal Business Name): INNOVATIVE DERMATOLOGY ALLIANCE CA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 AVENIDA DE LOS ROBLES
VISALIA CA
93291
US

IV. Provider business mailing address

13921 W GRAND AVE BLDG E
SURPRISE AZ
85374-2439
US

V. Phone/Fax

Practice location:
  • Phone: 559-733-5050
  • Fax:
Mailing address:
  • Phone: 559-733-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER UGOCHUKWU UGORJI REX
Title or Position: OWNER/PROVIDER
Credential:
Phone: 904-994-4533