Novato Dermatology Associates a Medical Corporation

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

G79619 Issued in CA

Legal business name

NOVATO DERMATOLOGY ASSOCIATES A MEDICAL CORPORATION

Practice address

867 Diablo Ave
Novato, CA 94947-4007

Phone

(415) 892-0754

Fax

(415) 897-3204

NPI assigned

Jan 23, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kim S Frederickson, MDNPI 1003995291

Title

Owner

Phone

(415) 892-0754

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Kim S Frederickson, MD

  • Dermatology Physician
  • Novato, CA
  • NPI 1003995291

  CA

  Medicare reassignment Care Compare group Authorized official
• Stephen Lewis Dalton, M.D.

  • Dermatology Physician
  • Novato, CA
  • NPI 1053318824

  CA

  Medicare reassignment Care Compare group
• Kimberly Frederick, CRNA

  • Certified Registered Nurse Anesthetist
  • Mansfield, OH
  • NPI 1427044726
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1541635200000",
    "number": "1003960063",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "867 DIABLO AVE",
            "city": "NOVATO",
            "state": "CA",
            "postal_code": "949474007",
            "telephone_number": "415-892-0754",
            "fax_number": "415-897-3204"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "867 DIABLO AVE",
            "city": "NOVATO",
            "state": "CA",
            "postal_code": "949474007",
            "telephone_number": "415-892-0754",
            "fax_number": "415-897-3204"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVATO DERMATOLOGY ASSOCIATES A MEDICAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-23",
        "last_updated": "2018-11-08",
        "status": "A",
        "authorized_official_last_name": "FREDERICKSON",
        "authorized_official_first_name": "KIM",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "415-892-0754",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "CA",
            "license": "G79619",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• North Bay Spine & Neuropathy Inc
• North Marin Community Services
• Novato Acupuncture and Herb Clinic Inc
• Novato Back Care and Sports Physical Therapy
• Novato Charter School
• Novato Endoscopy Center LLC
• Novato Family Dental Care
• Novato Fire Protection District
• Novato Healthcare Center, LLC
• Novato Internal Medicine Associates

• All providers in Novato, CA
• Dermatology Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.