MEDICARE: COAST DERMATOLOGY MEDICAL ASSOCIATES INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician	CA
2	207ND0900X	Dermatopathology Physician	CA
3	207NI0002X	Clinical & Laboratory Dermatological Immunology Physician	CA
4	207NP0225X	Pediatric Dermatology Physician	CA
5	207NS0135X	Procedural Dermatology Physician	CA
6	207N00000X	Dermatology Physician	CA

General Provider Information

NPI Number	:	1285926543
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COAST DERMATOLOGY MEDICAL ASSOCIATES INC

Provider Business Mailing Address
First Line	:	23550 HAWTHORNE BLVD
Second Line	:	STE 200
City	:	TORRANCE
State	:	CA
Zip	:	90505-4722
Country	:	US
Telephone Number	:	310-534-9131
Fax Number	:	310-534-9132

Provider Business Practice Location Address
First Line	:	23550 HAWTHORNE BLVD
Second Line	:	#200
City	:	TORRANCE
State	:	CA
Zip	:	90505-4722
Country	:	US
Telephone Number	:	310-373-2636
Fax Number	:	310-373-2633

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK KEVIN HOROWITZ
Credential	:	D.O.
Telephone Number	:	310-373-2636

Provider Enumeration Date	:	05/05/2011
Last Update Date	:	09/04/2012

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