Provider Demographics
NPI:1447334396
Name:SAN DIEGO DERMATOLOGY AND COSMETIC SURGERY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SAN DIEGO DERMATOLOGY AND COSMETIC SURGERY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHARMD
Authorized Official - Phone:619-287-1882
Mailing Address - Street 1:6367 ALVARADO CT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4904
Mailing Address - Country:US
Mailing Address - Phone:619-287-1882
Mailing Address - Fax:619-287-4121
Practice Address - Street 1:6367 ALVARADO CT
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4904
Practice Address - Country:US
Practice Address - Phone:619-287-1882
Practice Address - Fax:619-287-4121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83901207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19221Medicare UPIN
CAW15141AMedicare PIN
CAW15141BMedicare PIN
CAW15141Medicare PIN
CAW15141CMedicare PIN