Provider Demographics
NPI:1003082090
Name:OMNI DERMATOLOGY INCORPORATED
Entity Type:Organization
Organization Name:OMNI DERMATOLOGY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:RACETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-369-3634
Mailing Address - Street 1:11851 N 51ST AVE STE E130
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-2843
Mailing Address - Country:US
Mailing Address - Phone:236-299-9540
Mailing Address - Fax:
Practice Address - Street 1:11851 N 51ST AVE STE E130
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-2843
Practice Address - Country:US
Practice Address - Phone:480-954-3919
Practice Address - Fax:480-954-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4311207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty