Healthcare Provider Details

I. General information

NPI: 1548456825
Provider Name (Legal Business Name): DERMATOLOGY PATHOLOGY MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 LIVE OAK BLVD STE A-1
YUBA CITY CA
95991-3454
US

IV. Provider business mailing address

1007 LIVE OAK BLVD STE A-1
YUBA CITY CA
95991-3454
US

V. Phone/Fax

Practice location:
  • Phone: 530-673-3790
  • Fax: 530-673-5642
Mailing address:
  • Phone: 530-673-3790
  • Fax: 530-673-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number00A192080
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number00A192080
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number00A192080
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number00A192080
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number00A192080
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207ZI0100X
TaxonomyImmunopathology Physician
License Number00A192080
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number00A192080
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number00A192080
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number00A192080
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number00A192080
License Number StateCA
# 11
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number00A192080
License Number StateCA

VIII. Authorized Official

Name: DR. LEON MELVIN EDELSTEIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 530-673-3790