Provider Demographics
NPI:1427475540
Name:CERTIFIED DERMATOLOGY INC.
Entity type:Organization
Organization Name:CERTIFIED DERMATOLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BROOK
Authorized Official - Middle Name:LUCIEN
Authorized Official - Last Name:BROUHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:858-454-7123
Mailing Address - Street 1:1030 W 24TH ST STE C-2
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8319
Mailing Address - Country:US
Mailing Address - Phone:928-247-6825
Mailing Address - Fax:928-247-6827
Practice Address - Street 1:1030 W 24TH ST STE C-2
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8319
Practice Address - Country:US
Practice Address - Phone:928-247-6825
Practice Address - Fax:928-247-6827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97902207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty