Provider Demographics
NPI:1306369996
Name:CLEAR SKY DERMATOLOGY LLC
Entity Type:Organization
Organization Name:CLEAR SKY DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SVANCARA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-853-3762
Mailing Address - Street 1:17620 W COLUMBINE DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-5623
Mailing Address - Country:US
Mailing Address - Phone:623-853-3762
Mailing Address - Fax:
Practice Address - Street 1:2620 N 140TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2437
Practice Address - Country:US
Practice Address - Phone:623-219-4777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006549207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ006549OtherMEDICAL LICENSE NUMBER