NPIMap

Organization Active NPI

Bernardo Dermatology Medical Group Inc

  • Dermatology Physician
  • Poway, CA
National Provider Identifier
1407950785
Registry record updated Nov 6, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
G41388 Issued in CA
Legal business name
BERNARDO DERMATOLOGY MEDICAL GROUP INC
Practice address
15525 Pomerado Rd
Suite A2
Poway, CA 92064-2435
Phone
(858) 451-3311
Fax
(858) 451-1142
NPI assigned
Sep 8, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 6, 2007

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

Authorized official

Name
Ruth Ann Larson, MDNPI 1538167911
Title
President
Phone
(858) 451-3311

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X G41388 CA Primary
MOHS-Micrographic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207ND0101X G41388 CA
Dermatopathology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207ND0900X G49647 CA

Addresses

Primary practice location

15525 Pomerado Rd
Suite A2
Poway, CA 92064-2435

Mailing address

15525 Pomerado Rd
Suite A2
Poway, CA 92064-2435
Phone (858) 451-3311

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050707000457 CA Part B Supplier - Clinic/Group Practice 6507802964 Receives reassigned benefits from 9 practitioners
Practice locations: Poway, CA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0664519Bernardo Dermatology Medical Group15525 Pomerado Rd, Ste A2, Poway, CA 92064ComplianceAug 28, 2027

National Provider Directory

National Provider Directory

Locations

15525 Pomerado Rd
Ste A2
Poway, CA 92064
Phone (858) 451-3311

Practitioners & affiliated clinicians

Practitioners 12

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

NPI Registry JSON

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

{
    "created_epoch": "1157673600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1194307200000",
    "number": "1407950785",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15525 POMERADO RD",
            "address_2": "SUITE A2",
            "city": "POWAY",
            "state": "CA",
            "postal_code": "920642435",
            "telephone_number": "858-451-3311",
            "fax_number": "858-451-1142"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15525 POMERADO RD",
            "address_2": "SUITE A2",
            "city": "POWAY",
            "state": "CA",
            "postal_code": "920642435",
            "telephone_number": "858-451-3311",
            "fax_number": "858-451-1142"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BERNARDO DERMATOLOGY MEDICAL GROUP INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-08",
        "last_updated": "2007-11-06",
        "status": "A",
        "authorized_official_last_name": "LARSON",
        "authorized_official_first_name": "RUTH",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "858-451-3311",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "CA",
            "license": "G41388",
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "CA",
            "license": "G41388",
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": "CA",
            "license": "G49647",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Poway, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 6, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.