MEDICARE: DIRECT DERMATOLOGY PROFESSIONALS PC

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1417263922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRECT DERMATOLOGY PROFESSIONALS PC

Provider Business Mailing Address
First Line	:	228 HAMILTON AVE FL 3
Second Line	:
City	:	PALO ALTO
State	:	CA
Zip	:	94301-2583
Country	:	US
Telephone Number	:	510-241-2884
Fax Number	:	800-572-0683

Provider Business Practice Location Address
First Line	:	165 SAINT DOMINICS DR STE 120
Second Line	:
City	:	MANTECA
State	:	CA
Zip	:	95337-7802
Country	:	US
Telephone Number	:	510-241-2884
Fax Number	:	800-572-0683

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID WONG
Credential	:	MD
Telephone Number	:	855-944-7546

Provider Enumeration Date	:	08/20/2010
Last Update Date	:	11/06/2024

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