Provider Demographics
NPI:1114073285
Name:SOUTHWEST DERMATOLOGY INSTITUTE LTD
Entity Type:Organization
Organization Name:SOUTHWEST DERMATOLOGY INSTITUTE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAFKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-731-0933
Mailing Address - Street 1:2900 E DESERT INN RD
Mailing Address - Street 2:202
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3619
Mailing Address - Country:US
Mailing Address - Phone:702-731-0933
Mailing Address - Fax:702-731-9928
Practice Address - Street 1:2900 E DESERT INN RD
Practice Address - Street 2:202
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3619
Practice Address - Country:US
Practice Address - Phone:702-731-0933
Practice Address - Fax:702-731-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1255496014OtherNPI
NV002002934Medicaid
NV002002934Medicaid
NVV31819Medicare ID - Type Unspecified