Provider Demographics
NPI:1346420577
Name:DERMATOLOGY CENTER OF YUMA PLLC
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF YUMA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:LUCHETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-329-4761
Mailing Address - Street 1:2270 S RIDGEVIEW DR
Mailing Address - Street 2:STE 302
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-783-0169
Mailing Address - Fax:
Practice Address - Street 1:2270 S RIDGEVIEW DR
Practice Address - Street 2:STE 302
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364
Practice Address - Country:US
Practice Address - Phone:928-783-0169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY CENTER OF YUMA PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-05
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044009174400000X
AZ28963174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F26224Medicare UPIN