Provider Demographics
NPI:1306886429
Name:AFFILIATED DERMATOLOGISTS, INC.
Entity type:Organization
Organization Name:AFFILIATED DERMATOLOGISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN /PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEARLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-484-3331
Mailing Address - Street 1:3901 LAS POSAS RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010
Mailing Address - Country:US
Mailing Address - Phone:805-484-3331
Mailing Address - Fax:805-987-2118
Practice Address - Street 1:3901 LAS POSAS RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-484-3331
Practice Address - Fax:805-987-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG079257207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG297660Medicaid
ZZZ54249ZOtherBLUE SHIELD
CAOOG297660Medicaid