Provider Demographics
NPI:1962260208
Name:DERM LOUNGE PC
Entity type:Organization
Organization Name:DERM LOUNGE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:AWADALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-337-9393
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92609-0519
Mailing Address - Country:US
Mailing Address - Phone:714-798-2900
Mailing Address - Fax:949-216-3232
Practice Address - Street 1:1713 W KATELLA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6450
Practice Address - Country:US
Practice Address - Phone:714-798-2900
Practice Address - Fax:949-216-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-11
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty