MEDICARE: PACIFIC DERMATOLOGY INSTITUTE

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	A79221	CA

General Provider Information

NPI Number	:	1922486117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC DERMATOLOGY INSTITUTE

Provider Business Mailing Address
First Line	:	240 NEWPORT CENTER DR
Second Line	:	SUITE 105
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7512
Country	:	US
Telephone Number	:	946-644-2450
Fax Number	:	946-644-2451

Provider Business Practice Location Address
First Line	:	240 NEWPORT CENTER DR
Second Line	:	SUITE 105
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7512
Country	:	US
Telephone Number	:	946-644-2450
Fax Number	:	946-644-2451

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MR. JEFFREY BOTTOMLEY
Credential	:
Telephone Number	:	909-362-2966

Provider Enumeration Date	:	05/08/2015
Last Update Date	:	05/08/2015

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Directions to “PACIFIC DERMATOLOGY INSTITUTE ” Practice Location

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