Provider Demographics
NPI:1043323801
Name:GLENDORA DERMATOLOGIC AND COSMETIC SURGERY CENTER
Entity type:Organization
Organization Name:GLENDORA DERMATOLOGIC AND COSMETIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GORMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-335-1606
Mailing Address - Street 1:412 W CARROLL AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4240
Mailing Address - Country:US
Mailing Address - Phone:626-335-1606
Mailing Address - Fax:626-963-0575
Practice Address - Street 1:412 W. CARROLL AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4280
Practice Address - Country:US
Practice Address - Phone:626-335-1606
Practice Address - Fax:626-963-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS551093OtherPTAN (MEDICARE LEGACY #)
CAS551093OtherPTAN (MEDICARE LEGACY #)