Provider Demographics
NPI:1053823120
Name:FIFE DERMATOLOGY UTAH
Entity Type:Organization
Organization Name:FIFE DERMATOLOGY UTAH
Other - Org Name:VIVIDA DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:FIFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-255-6647
Mailing Address - Street 1:6460 MEDICAL CENTER ST STE 350
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2423
Mailing Address - Country:US
Mailing Address - Phone:702-255-6647
Mailing Address - Fax:702-920-8444
Practice Address - Street 1:1490 E FOREMASTER DRIVE
Practice Address - Street 2:SUITE 260
Practice Address - City:ST.GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-673-5373
Practice Address - Fax:702-673-5041
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIFE DERMATOLOGY, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-30
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCM808OtherMEDICARE
NV270773333OtherTAX-ID