Provider Demographics
NPI:1508035411
Name:AZ DERMATOLOGY LLC
Entity Type:Organization
Organization Name:AZ DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYSHRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-982-3337
Mailing Address - Street 1:4540 E BASELINE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4616
Mailing Address - Country:US
Mailing Address - Phone:480-982-3337
Mailing Address - Fax:480-497-4580
Practice Address - Street 1:4540 E BASELINE RD STE 109
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4616
Practice Address - Country:US
Practice Address - Phone:480-982-3337
Practice Address - Fax:520-374-2467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty