Provider Demographics
NPI:1154609584
Name:AMERICAN DERMATOLOGY CENTERS
Entity type:Organization
Organization Name:AMERICAN DERMATOLOGY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:LEDESMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-360-6661
Mailing Address - Street 1:PO BOX 15717
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209-1717
Mailing Address - Country:US
Mailing Address - Phone:310-360-6661
Mailing Address - Fax:310-360-6669
Practice Address - Street 1:416 N BEDFORD DR
Practice Address - Street 2:SUITE 306
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4322
Practice Address - Country:US
Practice Address - Phone:310-360-6661
Practice Address - Fax:310-360-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44761207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty