MEDICARE: MILL VALLEY DERMATOLOGY, INC

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	207ND0101X	MOHS-Micrographic Surgery Physician

General Provider Information

NPI Number	:	1578173936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILL VALLEY DERMATOLOGY, INC

Provider Business Mailing Address
First Line	:	655 REDWOOD HWY FRONTAGE RD STE 100
Second Line	:
City	:	MILL VALLEY
State	:	CA
Zip	:	94941-3031
Country	:	US
Telephone Number	:	415-634-8411
Fax Number	:	844-880-4434

Provider Business Practice Location Address
First Line	:	655 REDWOOD HWY FRONTAGE RD STE 100
Second Line	:
City	:	MILL VALLEY
State	:	CA
Zip	:	94941-3031
Country	:	US
Telephone Number	:	415-634-8411
Fax Number	:	844-880-4434

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. HAYDEE KNOTT
Credential	:	MD
Telephone Number	:	415-634-8411

Provider Enumeration Date	:	07/31/2020
Last Update Date	:	07/31/2020

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