=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386629905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CALIFORNIA DERMATOLOGY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2005
-----------------------------------------------------
Last Update Date | 01/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1125 E 17TH ST W-248
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-547-5151
-----------------------------------------------------
Fax | 714-541-2016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1125 E 17TH ST W-248
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-547-5151
-----------------------------------------------------
Fax | 714-547-4027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JONATHAN A BARON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 714-547-5151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------