=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740485010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE DERMATOLOGY CENTER OF PASADENA, A MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 07/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 S FAIR OAKS AVE SUITE 200
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-793-7790
-----------------------------------------------------
Fax | 626-793-9018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 S FAIR OAKS AVE SUITE 200
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-793-7790
-----------------------------------------------------
Fax | 626-793-9018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. HAN N. LEE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 626-793-7790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | A80177
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------