MEDICARE: PACIFIC 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	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1710025994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC DERMATOLOGY MEDICAL ASSOCIATES, INC

Provider Business Mailing Address
First Line	:	4553 QUAIL LAKES DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5257
Country	:	US
Telephone Number	:	209-951-1133
Fax Number	:	209-951-4708

Provider Business Practice Location Address
First Line	:	4553 QUAIL LAKES DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5257
Country	:	US
Telephone Number	:	209-951-1133
Fax Number	:	209-951-4708

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. KATHRYN BRIGITTE ROHRER
Credential	:	RMA
Telephone Number	:	209-951-1133

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	08/22/2020

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