Provider Demographics
NPI:1154592368
Name:FOOTHILL DERMATOLOGY MEDICAL CENTER
Entity type:Organization
Organization Name:FOOTHILL DERMATOLOGY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMARPAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIDHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:626-852-3376
Mailing Address - Street 1:2301 E FOOTHILL BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4000
Mailing Address - Country:US
Mailing Address - Phone:626-852-3376
Mailing Address - Fax:626-852-3375
Practice Address - Street 1:2301 E FOOTHILL BLVD
Practice Address - Street 2:STE 100
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4000
Practice Address - Country:US
Practice Address - Phone:626-852-3376
Practice Address - Fax:626-852-3375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73248174400000X
CAA73218207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A732480Medicaid
CA00A732480Medicaid