Provider Demographics
NPI:1093416893
Name:ARIZONA INSTITUTE OF DERMATOLOGY PAYSON LLC
Entity Type:Organization
Organization Name:ARIZONA INSTITUTE OF DERMATOLOGY PAYSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:U
Authorized Official - Last Name:REX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-951-0395
Mailing Address - Street 1:PO BOX 268920
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5646
Practice Address - Country:US
Practice Address - Phone:928-951-0395
Practice Address - Fax:928-492-9319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty