Provider Demographics
NPI:1417673112
Name:DESERT DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:DESERT DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEDKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-370-0510
Mailing Address - Street 1:2551 E CALLE SIN RUIDO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-7337
Mailing Address - Country:US
Mailing Address - Phone:269-370-0510
Mailing Address - Fax:
Practice Address - Street 1:1521 E TANGERINE RD STE 161
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6217
Practice Address - Country:US
Practice Address - Phone:520-771-0288
Practice Address - Fax:520-771-0289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ110342Medicaid