Provider Demographics
NPI:1033164538
Name:WHITE MOUNTAIN DERMATOLOGY LLC
Entity Type:Organization
Organization Name:WHITE MOUNTAIN DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRUAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-671-4086
Mailing Address - Street 1:288 N IRONWOOD DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85220-3830
Mailing Address - Country:US
Mailing Address - Phone:480-671-4086
Mailing Address - Fax:480-671-4105
Practice Address - Street 1:288 N IRONWOOD DR
Practice Address - Street 2:SUITE 105
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-3830
Practice Address - Country:US
Practice Address - Phone:480-671-4086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ070013565OtherRAIL ROAD MEDICARE
AZZ79805Medicare PIN
AZ070013565OtherRAIL ROAD MEDICARE
AZZ110998Medicare PIN