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General NPI Number Information
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NPI Number | 1780963991
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Entity Type | Organization
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Legal Business Name | LAKESIDE DERMATOLOGY - A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 08/05/2011
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Last Update Date | 10/06/2020
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Provider Practice Location Address
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Address Line | 1 SHRADER STREET #640
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City | SAN FRANCISCO
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State | CA
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Zip | 94117
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Country | US
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Telephone | 415-422-0000
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Fax | 415-424-4140
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Provider Business Mailing Address
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Address Line | 1 SHRADER STREET #640
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City | SAN FRANCISCO
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State | CA
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Zip | 94117
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Country | US
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Telephone | 415-422-0000
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Fax | 415-424-4140
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALICE NGOC DO
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Credential | DO
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Telephone | 415-317-7261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 20A9018
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License Number State | CA
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