Provider Demographics
NPI:1043536543
Name:ADVANCED DERMATOLOGY CARE, INC.
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:
Authorized Official - Last Name:TING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-328-0255
Mailing Address - Street 1:2262 CAMINO RAMON
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583
Mailing Address - Country:US
Mailing Address - Phone:925-328-0255
Mailing Address - Fax:925-328-0257
Practice Address - Street 1:2262 CAMINO RAMON
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583
Practice Address - Country:US
Practice Address - Phone:925-328-0255
Practice Address - Fax:925-328-0257
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DERMATOLOGY CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-09
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82266207N00000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU81729Medicare UPIN