NPIMap

Organization Active NPI

Alamitos Dermatological Medical Clinic a Professional Corp

  • Specialist
  • Tustin, CA
National Provider Identifier
1891986204
Registry record updated Feb 25, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
ALAMITOS DERMATOLOGICAL MEDICAL CLINIC A PROFESSIONAL CORP
Practice address
12721 Newport Ave
Suite 4
Tustin, CA 92780-8030
Phone
(714) 838-5680
Fax
(714) 544-1321
NPI assigned
Aug 9, 2007
Last updated
Feb 25, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 25, 2016

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

Authorized official

Name
Monica T Dennis
Title
Administrator
Phone
(562) 619-8440

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X Primary

Addresses

Primary practice location

12721 Newport Ave
Suite 4
Tustin, CA 92780-8030

Mailing address

12721 Newport Ave
Suite 4
Tustin, CA 92780-8030
Phone (714) 838-5680

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040514001203 CA Part B Supplier - Clinic/Group Practice 3971593542 Receives reassigned benefits from 5 practitioners
3 other NPIs on this enrollment
Practice locations: Huntington Beach, CA; Los Alamitos, CA; Mission Viejo, CA; Tustin, CA

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

5451 La Palma Ave
Ste 27
La Palma, CA 90623
Phone (714) 523-9493

3801 Katella Ave
Ste 101
Los Alamitos, CA 90720
Phone (562) 598-5893

1401 Avocado Ave
Ste 710
Newport Beach, CA 92660
Phone (714) 640-1611

12721 Newport Ave
Tustin, CA 92780
Phone (714) 838-5680

12721 Newport Ave
Ste 4
Tustin, CA 92780
Phone (714) 838-5680

13372 Newport Ave
Ste H
Tustin, CA 92780
Phone (714) 838-5680

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1186617600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1456358400000",
    "number": "1891986204",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12721 NEWPORT AVE",
            "address_2": "SUITE 4",
            "city": "TUSTIN",
            "state": "CA",
            "postal_code": "927808030",
            "telephone_number": "714-838-5680",
            "fax_number": "714-544-1321"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12721 NEWPORT AVE",
            "address_2": "SUITE 4",
            "city": "TUSTIN",
            "state": "CA",
            "postal_code": "927808030",
            "telephone_number": "714-838-5680",
            "fax_number": "714-544-1321"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ALAMITOS DERMATOLOGICAL MEDICAL CLINIC A PROFESSIONAL CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-09",
        "last_updated": "2016-02-25",
        "status": "A",
        "authorized_official_last_name": "DENNIS",
        "authorized_official_first_name": "MONICA",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "562-619-8440"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tustin, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 25, 2016; 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.