Provider Demographics
NPI:1548456825
Name:DERMATOLOGY PATHOLOGY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:DERMATOLOGY PATHOLOGY MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:EDELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-673-3790
Mailing Address - Street 1:1007 LIVE OAK BLVD
Mailing Address - Street 2:STE A-1
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-3454
Mailing Address - Country:US
Mailing Address - Phone:530-673-3790
Mailing Address - Fax:530-673-5642
Practice Address - Street 1:1007 LIVE OAK BLVD
Practice Address - Street 2:STE A-1
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-3454
Practice Address - Country:US
Practice Address - Phone:530-673-3790
Practice Address - Fax:530-673-5642
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY PATHOLOGY MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A192080207K00000X, 207N00000X, 207NP0225X, 207NS0135X, 207ZD0900X, 207ZI0100X, 207ZP0102X, 207ZP0213X, 208D00000X, 209800000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathologyGroup - Single Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric PathologyGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No209800000XAllopathic & Osteopathic PhysiciansLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A192080Medicaid
CAZZZ29262ZMedicare Oscar/Certification
CAA21651Medicare UPIN