Provider Demographics
NPI:1083841225
Name:SKINNER, DANIEL PETERSON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:PETERSON
Last Name:SKINNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 W SOUTHERN AVE
Mailing Address - Street 2:102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4702
Mailing Address - Country:US
Mailing Address - Phone:480-835-5532
Mailing Address - Fax:480-962-0106
Practice Address - Street 1:2050 W SOUTHERN AVE STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4702
Practice Address - Country:US
Practice Address - Phone:480-835-5532
Practice Address - Fax:480-962-0106
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010010429207N00000X
AZ48691207NS0135X, 207ND0101X
AL32259207NS0135X
AZR71509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-37085OtherBLUE
AL511-37083OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL511-37085OtherBLUE
AL511-37082OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL511-37079OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL511-37081OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL511-37084OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL511-37082OtherBLUE CROSS BLUE SHIELD OF ALABAMA