Provider Demographics
NPI:1750720264
Name:PRESIDIO DERMATOLOGY, INC
Entity type:Organization
Organization Name:PRESIDIO DERMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:HEWITT
Authorized Official - Last Name:KAYMEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-933-8490
Mailing Address - Street 1:3905 SACRAMENTO ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1636
Mailing Address - Country:US
Mailing Address - Phone:415-933-8490
Mailing Address - Fax:
Practice Address - Street 1:3905 SACRAMENTO ST
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1636
Practice Address - Country:US
Practice Address - Phone:415-933-8490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53235207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFK1688677OtherDEA
CAFK1688677OtherDEA