Organization
GOLDEN COAST DERMATOLOGY, SKIN CANCER AND VEIN CENTER PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM TIDWELL MD (OWNER/PHYSICIAN)
(270) 933-2109
Entity
Organization
Contact information
Practice address
26732 CROWN VALLEY PKWY STE 571, MISSION VIEJO, CA 92691-7305
(270) 933-2109
Mailing address
26732 CROWN VALLEY PKWY STE 571, MISSION VIEJO, CA 92691-7305
(270) 933-2109
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A147575
CA STATE LICENSE
CA
Enumeration date
11/20/2019
Last updated
03/27/2020
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