Basic Information
| Provider Information | |||||||||
| NPI: | 1447620539 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY CHILDREN'S SPECIALTY MEDICAL GROUP - DEPT OF DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535700 | ||||||||
| FaxNumber: | 5593535708 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535700 | ||||||||
| FaxNumber: | 5593535708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2015 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | KAJI | ||||||||
| AuthorizedOfficialFirstName: | DEVONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5593535700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VALLEY CHILDREN'S SPECIALTY MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NP0225X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology |
No ID Information.