Provider Demographics
NPI:1215559471
Name:INNOVATIVE DERMATOLOGY ALLIANCE AZ, PC
Entity Type:Organization
Organization Name:INNOVATIVE DERMATOLOGY ALLIANCE AZ, PC
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:MD
Authorized Official - Phone:904-994-4533
Mailing Address - Street 1:3318 W LUCIA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-5884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 BRALLIAR RD
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390
Practice Address - Country:US
Practice Address - Phone:602-971-0268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty