Provider Demographics
NPI:1104991603
Name:DERMATOLOGY ASSOCIATES OF SOUTHERN CALIFORNIA, INC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF SOUTHERN CALIFORNIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:YASHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-498-2131
Mailing Address - Street 1:1850 REDONDO AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-1251
Mailing Address - Country:US
Mailing Address - Phone:562-498-2131
Mailing Address - Fax:562-498-2535
Practice Address - Street 1:1850 REDONDO AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-1251
Practice Address - Country:US
Practice Address - Phone:562-498-2131
Practice Address - Fax:562-498-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86029207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18770Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER