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General NPI Number Information
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NPI Number | 1700371275
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Entity Type | Organization
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Legal Business Name | ICECREAMWALA DERMATOLOGY INC
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Dates
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Enumeration Date | 06/27/2018
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Last Update Date | 07/02/2018
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Provider Practice Location Address
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Address Line | 2435 WEBSTER ST STE 101
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City | BERKELEY
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State | CA
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Zip | 94705
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Country | US
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Telephone | 510-646-8070
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Fax | 833-484-7048
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Provider Business Mailing Address
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Address Line | 2435 WEBSTER ST STE 101
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City | BERKELEY
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State | CA
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Zip | 94705-2050
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Country | US
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Telephone | 510-646-8070
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Fax | 833-484-7048
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | DEVIKA ICECREAMWALA
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Credential | MD
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Telephone | 510-646-8070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207NP0225X
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Taxonomy Name | Pediatric Dermatology Physician
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State | CA
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