Basic Information
| Provider Information | |||||||||
| NPI: | 1154496248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REDWOOD EMPIRE DERMATOLOGY INC | ||||||||
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| OtherOrganizationName: | DERMATOLOGY ASSOCIATES OF SONOMA COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 990 SONOMA AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954044813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075794239 | ||||||||
| FaxNumber: | 7075790459 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 SONOMA AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954044813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075794239 | ||||||||
| FaxNumber: | 7075790459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WESTROM | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | RAYMOND | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7075794239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D., PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.