Basic Information
Provider Information | |||||||||
NPI: | 1841433182 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARIN DERMATOLOGY ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1310 COMMERCE ST | ||||||||
Address2: | SUITE B | ||||||||
City: | PETALUMA | ||||||||
State: | CA | ||||||||
PostalCode: | 949541469 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7077787862 | ||||||||
FaxNumber: | 7077780969 | ||||||||
Practice Location | |||||||||
Address1: | 1660 2ND ST | ||||||||
Address2: |   | ||||||||
City: | SAN RAFAEL | ||||||||
State: | CA | ||||||||
PostalCode: | 949012707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4152590131 | ||||||||
FaxNumber: | 4152590133 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/16/2009 | ||||||||
LastUpdateDate: | 03/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BANDT | ||||||||
AuthorizedOfficialFirstName: | ANYA | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4152590131 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | A65186 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207ND0900X | A65186 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X | A65186 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | A65186 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.