Provider Demographics
NPI:1174898654
Name:GREENBRAE DERMATOLOGY, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:GREENBRAE DERMATOLOGY, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCRETIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-925-0550
Mailing Address - Street 1:1300 S ELISEO DR STE 207
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2015
Mailing Address - Country:US
Mailing Address - Phone:415-925-0550
Mailing Address - Fax:415-925-9062
Practice Address - Street 1:1300 S ELISEO DR STE 207
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2015
Practice Address - Country:US
Practice Address - Phone:415-925-0550
Practice Address - Fax:415-925-9062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97783207ND0101X, 207NP0225X, 207N00000X, 207ND0900X, 207NS0135X
CAG53455207NP0225X, 207ND0900X, 207NS0135X, 207N00000X
CAG40606207N00000X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty