MEDICARE: NORTH BAY DERMATOLOGY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J5792	OTHER	CA	RAILTOAD MEDICARE

General Provider Information

NPI Number	:	1275622664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH BAY DERMATOLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	106 LYNCH CREEK WAY
Second Line	:	SUITE #8
City	:	PETALUMA
State	:	CA
Zip	:	94954-2356
Country	:	US
Telephone Number	:	707-763-6816
Fax Number	:	707-763-1730

Provider Business Practice Location Address
First Line	:	106 LYNCH CREEK WAY
Second Line	:	SUITE #8
City	:	PETALUMA
State	:	CA
Zip	:	94954-2356
Country	:	US
Telephone Number	:	707-763-6816
Fax Number	:	707-763-1730

Authorized Official
Title or Position	:	PRACTICE OWNER
Name	:	SANTIAGO CENTURION
Credential	:	M.D.
Telephone Number	:	707-763-6816

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	06/25/2019

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