Provider Demographics
NPI:1194750661
Name:SPECTRUM DERMATOLOGY MEDICAL ASSOCS CORP.
Entity type:Organization
Organization Name:SPECTRUM DERMATOLOGY MEDICAL ASSOCS CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:S
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-372-6900
Mailing Address - Street 1:665 MUNRAS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-3134
Mailing Address - Country:US
Mailing Address - Phone:831-372-6900
Mailing Address - Fax:831-372-0266
Practice Address - Street 1:665 MUNRAS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-3134
Practice Address - Country:US
Practice Address - Phone:831-372-6900
Practice Address - Fax:831-372-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46142207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831131069OtherNPI
CAF22315Medicare UPIN
CAZZZ01576ZMedicare PIN
CA00A461420Medicare PIN
CA00A461421Medicare PIN