Organization
GOLDEN COAST DERMATOLOGY, SKIN CANCER AND VEIN CENTER PC
Active
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
Update your record
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