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General NPI Number Information
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NPI Number | 1235738576
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Entity Type | Organization
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Legal Business Name | GOLDEN STATE DERMATOLOGY ASSOCIATES, INC.
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Dates
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Enumeration Date | 10/19/2020
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Last Update Date | 10/19/2020
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Provider Practice Location Address
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Address Line | 6769 N FRESNO ST
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City | FRESNO
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State | CA
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Zip | 93710-3715
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Country | US
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Telephone | 559-435-0337
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Fax |
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Provider Business Mailing Address
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Address Line | 355 LENNON LN STE 255
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City | WALNUT CREEK
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State | CA
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Zip | 94598-2496
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Country | US
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Telephone | 925-932-7704
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | JEFFREY THOMAS BORTZ
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Credential |
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Telephone | 925-932-7704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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