Provider Demographics
NPI:1306940465
Name:DERMATOLOGICARE MEDICAL CORPORATION
Entity type:Organization
Organization Name:DERMATOLOGICARE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:BABAPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-247-0337
Mailing Address - Street 1:414 N CAMDEN DR
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4532
Mailing Address - Country:US
Mailing Address - Phone:310-247-0337
Mailing Address - Fax:310-247-0343
Practice Address - Street 1:414 N CAMDEN DR
Practice Address - Street 2:SUITE 1001
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4532
Practice Address - Country:US
Practice Address - Phone:310-247-0337
Practice Address - Fax:310-247-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77137207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H23584Medicare UPIN
CAW15559Medicare ID - Type Unspecified