Provider Demographics
NPI:1053957456
Name:GOLDEN COAST DERMATOLOGY, SKIN CANCER AND VEIN CENTER PC
Entity type:Organization
Organization Name:GOLDEN COAST DERMATOLOGY, SKIN CANCER AND VEIN CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-933-2109
Mailing Address - Street 1:26732 CROWN VALLEY PKWY STE 571
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-7305
Mailing Address - Country:US
Mailing Address - Phone:270-933-2109
Mailing Address - Fax:
Practice Address - Street 1:26732 CROWN VALLEY PKWY STE 571
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-7305
Practice Address - Country:US
Practice Address - Phone:270-933-2109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-20
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA147575OtherCA STATE LICENSE