MEDICARE: SOCAL SKIN AND SURGERY

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710687157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOCAL SKIN AND SURGERY

Provider Business Mailing Address
First Line	:	12555 W JEFFERSON BLVD STE 202
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-7047
Country	:	US
Telephone Number	:	424-543-0066
Fax Number	:

Provider Business Practice Location Address
First Line	:	12555 W JEFFERSON BLVD STE 202
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-7047
Country	:	US
Telephone Number	:	424-543-0066
Fax Number	:

Authorized Official
Title or Position	:	DERMATOLOGIST
Name	:	DR. JENNY ZHUOYUE WANG
Credential	:	MD
Telephone Number	:	240-246-3164

Provider Enumeration Date	:	03/06/2023
Last Update Date	:	07/04/2023

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Directions to “SOCAL SKIN AND SURGERY ” Practice Location

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