Provider Demographics
NPI:1699872630
Name:RANDY JACOBS DERMATOLOGY INC.
Entity type:Organization
Organization Name:RANDY JACOBS DERMATOLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-672-7673
Mailing Address - Street 1:23905 CLINTON KEITH RD
Mailing Address - Street 2:114
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7899
Mailing Address - Country:US
Mailing Address - Phone:951-672-7673
Mailing Address - Fax:951-672-1197
Practice Address - Street 1:27640 ENCANTO DR
Practice Address - Street 2:# B
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-3304
Practice Address - Country:US
Practice Address - Phone:951-672-7673
Practice Address - Fax:951-672-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA049395207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE25046Medicare UPIN
CA00G616540Medicare PIN