Provider Demographics
NPI:1043315195
Name:CENTRAL VALLEY DERMATOLOGY MEDICAL GROUP, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CENTRAL VALLEY DERMATOLOGY MEDICAL GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BASIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HANTASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:408-204-8946
Mailing Address - Street 1:3800 GEER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-1146
Mailing Address - Country:US
Mailing Address - Phone:209-250-1442
Mailing Address - Fax:209-668-4992
Practice Address - Street 1:3800 GEER RD STE 200
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1146
Practice Address - Country:US
Practice Address - Phone:209-250-1442
Practice Address - Fax:209-668-4992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA7300OtherRAILROAD MEDICARE GROUP#
ZZZ20312ZOtherMEDICARE GROUP ID#