=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437903481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY INSTITUTE FOR SKIN CANCER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2024
-----------------------------------------------------
Last Update Date | 04/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2701 CHESTER AVENUE SUITE 103
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-837-7084
-----------------------------------------------------
Fax | 661-837-7186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 SAN REMO DRIVE
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-852-5980
-----------------------------------------------------
Fax | 661-837-7186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GEOVER FERNANDEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 661-803-2428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------