Basic Information
| Provider Information | |||||||||
| NPI: | 1811586134 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED DERMATOLOGY OF ROSEVILLE, PC | ||||||||
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| OtherOrganizationName: | SELECT OR ENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 EXCHANGE CT STE 110 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334314450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1412 BLUE OAKS BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957477143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167847546 | ||||||||
| FaxNumber: | 9167847548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | HALEY | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED GROUP OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5613142000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.